Figure 1. The 2003 international distribution of indoor tanning restrictions.
Figure 2. The 2011 international distribution of indoor tanning restrictions.
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Pawlak MT, Bui M, Amir M, Burkhardt DL, Chen AK, Dellavalle RP. Legislation Restricting Access to Indoor Tanning Throughout the World. Arch Dermatol. 2012;148(9):1006–1012. doi:10.1001/archdermatol.2012.2080
Objective To compile current legislation of indoor tanning throughout the world and compare them with existing legislation found in 2003.
Design Cross-sectional study.
Participants All nations with legislation regarding access to indoor tanning found through web-based Internet search.
Main Outcome Measures Number of nations with legislation and changes to laws regarding access to indoor tanning since 2003.
Results The number of countries with nationwide indoor tanning legislation restricting youth 18 years or younger increased from 2 countries in 2003 to 11 countries in 2011. Six states or territories in Australia restricted indoor tanning in all minors; a province and a region in Canada implemented youth tanning laws; and 8 states, in addition to 3 preexisting state laws, in the United States implemented indoor tanning legislation since 2003.
Conclusion Since 2003, access to indoor tanning has become increasingly restricted around the world.
In the 1970s, commercial tanning beds for cosmetic use were introduced to the public. In less than 3 decades, over half of Northern European men and women ages 18 to 50 years reported using tanning beds.1 Tanning bed use varies by location and demographics. For instance, the prevalence of ever having used indoor tanning was 5% in Northern Italy in 1986, while the prevalence was 57% in Swedish women in 2001.2 On average, 1 million people use tanning beds per day in the United States, and nearly 28 million people use tanning beds annually.3,4 From the 2005 National Health Interview data, Heckman et al5 found that 20% of people ages 18 to 29 years reported tanning. While UV phototherapy is prescribed to treat numerous pathologic skin conditions, including psoriasis, the legislation described herein applies to medically unsupervised commercial indoor tanning salons.
Long-term health risks of indoor tanning are premature aging, immune suppression, cataract and other eye injuries, and skin cancers.6 Skin cancer is the most common cancer in the United States, and approximately 20% of Americans will develop skin cancer in their lifetime.7 Evidence strongly points to the association of tanning bed use with squamous cell and basal cell carcinomas, and results are increasingly demonstrating an association between tanning bed use and melanoma.8-11 Risk factors of melanoma are family history, physical characteristics, nevi, moles, and UV light. While nonmodifiable factors increase the relative risks of melanoma from 1.4 to 11.0 times, UV light, the only modifiable risk factor, increases relative risk of melanoma by 1.8 times.12
Studies performed in the United States and Europe reported an increased risk of melanoma in tanning bed users.11,13-15 Since the advent of tanning beds, the prevalence of tanning bed use and melanoma are rising, particularly in women ages 15 to 39 years. A study conducted with the Surveillance Epidemiology and End Results database demonstrated a 2.7% annual increase of melanoma from 1992 to 2004.14
In 2003, the International Commission on Non-Ionizing Radiation Protection provided recommendations against the use of UV-emitting appliances for nonmedical purposes and classified youth 18 years or younger as a high-risk group.16 In 2007, the International Agency for Research on Cancer (IARC) presented a meta-analysis demonstrating a 75% increased risk of melanoma with the use of tanning beds before the age of 30 years.17 Then in 2009, the World Health Organization (WHO) reclassified all forms of sunlamps, tanning beds, and UV light as class 1 carcinogens, which are known to cause cancer to humans.18,19 In addition, in the United States, the American Medical Association and American Academy of Dermatology recommended restricting indoor tanning for youth 18 years or younger.18,20 Such recognition paved the way for increasing support to restrict access to indoor tanning.
In 2003, a study compared youth access laws of indoor tanning with the more established youth access laws regarding tobacco use.21 This study found more variability in the access laws regulating tanning than in those restricting tobacco use in minors and called for uniform age restrictions to indoor tanning in an effort to reduce uninformed carcinogen exposure.21 The study, which originally included rapidly evolving legislation from 6 countries was updated in 2007 to cover 25 states and 8 countries.22 Our objective in this study was to compile a comprehensive list of 2011 legislation of indoor tanning restrictions and compare them with 2003 statutes throughout the world.
From January 2011 to June 2011, a web-based search using Internet search engines Google and Yahoo! was conducted on access to indoor tanning. Computerized searches for the terms “indoor tanning,” “tanning bed,” “sunbed,” “radiation,” “solarium,” “statues,” “legislation,” “law,” and “bylaw.”
Preliminary search results were presented at the 22nd World Congress of Dermatology on May 26, 2011, in Seoul, Korea, and information and verification were elicited from attendees through an ad hoc inquiry. Twenty dermatologists attended the presentation, and representatives from Ireland and the European Academy of Dermatology and Venerology provided input.
France was the first country to institute an age restriction on indoor tanning for youth 18 years or younger in 1997, and Brazil followed suit in 2002.23 By 2003, France, Brazil, and the province of New Brunswick in Canada had legislation restricting indoor tanning for youth 18 years or younger (Figure 1). Three states in the United States had indoor tanning age restrictions for youth at varying ages in 2003: Wisconsin restricted those 16 years or younger, Illinois restricted those 14 years or younger, and Texas restricted those 13 years or younger from indoor tanning.
By 2011, Brazil banned indoor tanning for all age groups (Figure 2). The number of countries that had nationwide indoor tanning laws for youth 18 years or younger increased from 2 countries (France and Brazil) in 2003 to 11 countries in 2011 (Table 1). These 11 countries are France, Spain, Portugal, Germany, Austria, Belgium, England, Wales, Northern Ireland, Scotland, and Brazil. In Canada, while the province of New Brunswick no longer restricted youth indoor tanning, the province of Nova Scotia instituted a law restricting youth 19 years or younger, and the Capital Regional District of British Columbia restricted youth 18 years or younger. Six states or territories in Australia added legislation for youth 18 years or younger. The number of states in the United States that had indoor tanning legislation for youth increased from 3 states in 2003 to 11 states in 2011 (Table 2). California increased the indoor tanning restriction to youth 18 years or younger and became the first state in the United States to restrict indoor tanning to all minors. Of the remaining 39 states, 21 states require parental consent or accompaniment for tanning bed use.
The meta-analysis presented by the IARC demonstrated an increased risk of melanoma with the use of tanning beds before the age of 30.17 This IARC study and the reclassification of sunlamps, tanning beds, and UV light as class 1 carcinogens by WHO catalyzed increasing international support for age restrictions on youth indoor tanning.18,19
In addition, several studies were published that reinforced the association between indoor tanning and melanoma in 2010 and 2011. Veierød et al38 followed a cohort of Scandinavian women for 14 years and reported a 38% increased risk of melanoma in women younger than 40 years who used a tanning bed 1 or more times monthly in any decade. Furthermore, Lazovich et al11 reported a dose-response relationship between indoor tanning and melanoma. Compared with nonusers of tanning beds, the risk of melanoma was 1.3 times greater for people who used tanning beds for 1 to 10 sessions, 1.8 times greater for people who used tanning beds for 11 to 24 sessions, and 2.7 times greater for people who used tanning beds more than 100 sessions. A recent Swedish cohort study39 demonstrated negative associations of solar UV exposure with all-cause mortality and cardiovascular mortality, but positive associations of artificial UV exposure with all-cause mortality and cardiovascular mortality. The rationale for this remains unknown, and the researchers called for further investigation into the effects and differences of natural and artificial UV radiation.40
The effects of youth indoor tanning legislation are currently being evaluated for efficacy. Hirst et al41 estimated that restricting indoor tanning to minors has the potential to prevent skin cancers and related medical costs. For instance, adherence to the indoor tanning age restriction in Australia could prevent 18 to 30 melanomas and 200 to 251 squamous cell carcinomas per 100 000 individuals and avoid associated costs of over A$250 000 per 100 000 individuals. Another study, conducted by Mayer et al,15 described factors influencing indoor tanning rates at multiple levels, including environmental and policy levels. It found increasing indoor tanning use with increasing age in adolescents. An absolute 18.3% increase in tanning was found for ages 14 to 17 years. Increased tanning in older adolescents may be the result of a number of factors, such as peer and parental influence, proximity of salons to schools and homes, and lack of tanning restrictions for older adolescents. As demonstrated in our study, many states require only parental consent or parental accompaniment and do not restrict indoor tanning for older adolescents. We agree with Mayer et al15 that legislation restricting all minors has a greater impact in reducing youth indoor tanning than legislation requiring only parental consent or parental accompaniment. Currently, 21 states require only parental consent or accompaniment for tanning bed use. Strong lobbying efforts by the tanning bed industry and proceedings after a bill was filed, including protracted debates, were cited as 2 of the strongest barriers against passing legislation restricting indoor tanning.42
Recently, New Brunswick's government failed to maintain its ban on the use of tanning beds for those younger than 18 years. Instead, voluntary guidelines were imposed that stated that those younger than 18 years should not be allowed in tanning beds. Although the exact reason for this change is unclear, it may reflect difficulties involved with passing tanning bed legislation as seen in the United States and later implementation of these regulations.42,43
Other interventions could assist in decreasing youth indoor tanning, including promoting public health announcements, implementing a tanning bed use tax, restricting marketing directed toward youth, restricting the location of tanning salons, and mandating education for tanning bed users. Although it is difficult to establish the exact role and value of mass media interventions, such as public health announcements through television, radio, billboards, and newspapers, on tobacco cessation, various studies showed positive results on smoking behavior for up to 8 years after the campaign.44 In 2010, the United States implemented a 10% tax on tanning services. It is yet to be seen how effective the tax will be in decreasing youth indoor tanning. However, an absolute increase of 10% tax on tobacco products demonstrated decreased smoking by at least 4%.45
Another study demonstrated that tanning industries use direct advertisements to youth, particularly in schools.46 Restricting direct marketing in school newspapers and tanning salon locations near schools could further reduce youth tanning. In addition, several tanning safety tools are available, such as educational videos that describe individual tanning users who have developed melanoma and UV photography to demonstrate existing sun damage, but these tools are not required for educating youth in tanning salons before tanning bed use.47,48 Together, restriction policies and community interventions will have a greater impact on decreasing indoor tanning in youths.
Since 2003, youth access to indoor tanning has become increasingly restricted throughout the world as accumulating evidence demonstrated an association between melanoma and indoor tanning. Additional countries and states are developing indoor tanning restrictions or making their existing legislation more restrictive. In Australia, starting in 2015, New South Wales will ban all age groups from indoor tanning. In Europe, the Republic of Ireland and Finland are developing youth access legislation. Furthermore, 16 states in the United States are considering restricting indoor tanning access for individuals 18 years or younger.
Indoor tanning legislation is constantly evolving, and the National Conference of State Legislatures provides an updated web registry of indoor tanning legislation in the United States. We recommend a similar web registry for legislation throughout the world. This indoor tanning legislation registry would enable posting of current indoor tanning policies and assist nations to collaborate in advocacy efforts.
Correspondence: Robert P. Dellavalle, MD, PhD, MSPH, Dermatology Service, Department of Veteran Affairs Medical Center, 1055 Clermont St, PO Box 165, Denver, CO 80220 (email@example.com).
Accepted for Publication: May 10, 2012.
Published Online: July 16, 2012. doi:10.1001/archdermatol.2012.2080
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Pawlak and Dellavalle. Acquisition of data: Pawlak and Burkhardt. Analysis and interpretation of data: Pawlak, Bui, Amir, Chen, and Dellavalle. Drafting of the manuscript: Pawlak. Critical revision of the manuscript for important intellectual content: Pawlak, Bui, Amir, Burkhardt, Chen, and Dellavalle. Administrative, technical, and material support: Pawlak, Burkhardt, and Dellavalle. Study supervision: Chen and Dellavalle.
Financial Disclosure: None reported.
Funding/Support: Dr Pawlak was supported in part by Health Resources and Services Administration (HRSA) grant No. D33HP02610 to the University of Colorado Preventive Medicine Residency Program.
Disclaimer: The opinions expressed in this article represent those of the authors and not of the government of the United States. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.
Previous Presentations: The results of this study were presented at the World Congress of Dermatology; May 26, 2011; Seoul, Korea; and the American Academy of Dermatology Conference; March 16-20, 2012; San Diego, California.
Additional Contributions: The figures were made by Kemp Weston.
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