Tanning Salon Compliance Rates in States With Legislation to Protect Youth Access to UV Tanning

Key Points

Question  How compliant are the tanning salons in 42 states and the District of Columbia with current indoor tanning legislation?

Findings  In this cross-sectional telephone survey of 427 tanning salons in 42 states and the District of Columbia, 159 tanning salons were out of compliance with state legislation. Statistically significant decreases in compliance were found for rural, independently owned, and southern US tanning salons.

Meaning  Tanning salon compliance with state laws restricting access to minors is unsatisfactory, and monitoring and enforcement efforts are needed to ensure compliance with these laws that are intended to minimize the harmful effects of UV tanning in minors.

Importance  The US Food and Drug Administration has classified tanning beds as carcinogenic. Most states have enacted legislation to prevent or create barriers for minors accessing tanning establishments. Determining tanning salon compliance with legislation would provide an indication of the influence of legislation at preventing exposure to the carcinogen in minors.

Objectives  To investigate compliance rates in the 42 states and the District of Columbia with legislation restricting tanning bed use in minors and to identify differences in compliance based on population, regional location, salon ownership, age group being regulated, and time since the law was enacted.

Design, Setting, and Participants  This investigation was a cross-sectional telephone survey conducted between February 1, 2015, and April 30, 2016, by callers posing as minors attempting to schedule a tanning appointment. The setting was tanning salons in the 42 states and the District of Columbia that currently have legislation restricting tanning bed use in minors. Included in the study were 427 tanning salons, 10 randomly selected from each state or territory with tanning legislation.

Main Outcomes and Measures  Overall compliance of tanning salons with state tanning legislation and differences in compliance based on community population, regional location, independent vs chain tanning salon, age group being regulated, and time since the law was enacted.

Results  Of the 427 tanning salons surveyed, overall noncompliance with state legislation was 37.2% (n = 159). There were more noncompliant tanning salons in rural locations (45.5%; 95% CI, 37.5%-53.7%; P = .009), southern regions of the United States (49.4%; 95% CI, 41.4%-57.4%; P = .001), independently owned salons (43.9%; 95% CI, 37.3%-50.6%; P = .003), states with younger age groups being regulated (53.5%; 95% CI, 45.7%-61.2%; P < .001), and states with more than one tanning regulation (50.0%; 95% CI, 42.0%-58.0%; P < .001). No difference was found based on time since the law was enacted.

Conclusions and Relevance  Compliance with state legislation aimed at limiting tanning bed use among US minors is unsatisfactory, indicating that additional efforts to enforce the laws and education of the harmful effects of UV tanning are necessary, especially in rural, independently owned, and tanning salons in southern regions, which have decreased compliance rates.

It is estimated that banning indoor tanning for minors younger than 18 years would prevent 61 839 melanomas and 6735 melanoma deaths and save $342.9 million in treatment costs.¹ The World Health Organization² supports a ban on indoor tanning for anyone younger than 18 years. While a federal indoor tanning ban does not yet exist, the US Food and Drug Administration³ has required labeling on indoor tanning devices and promotional materials, stating that they should not be used by anyone younger than 18 years. There have been 42 states and the District of Columbia that passed legislation limiting the use of indoor tanning devices for minors,⁴ yet almost 1.9 million high school students in the United States are still engaging in indoor tanning.⁵

Several studies have assessed tanning salon compliance with state legislation; however, most studies assessed compliance in single states,^6,7 a few states,⁸ or only large cities.⁹ To our knowledge, no studies have assessed compliance in rural locations, by region of the country, or comparing independent tanning facilities vs large chain operations. Our objective was to investigate whether tanning facilities in states with legislation effectively restrict youth access to indoor tanning and whether differences in compliance exist in rural vs urban locations, by region in the United States, between independent vs chain tanning salons, based on age group being regulated, or based on time frame when the law was enacted.

This investigation was a cross-sectional telephone survey in which 3 of us (M.S.W., B.B., and L.B.) made telephone calls to 10 tanning facilities in each of the 42 states and District of Columbia (n = 427) with tanning legislation for minors randomly selected by zip code. The study was approved by the Marshfield Clinic Institutional Review Board.

All zip codes for each state or territory were collected and randomized from a website (http://www.unitedstateszipcodes.org). For the first 10 randomly selected zip codes, a search was performed online (http://www.yellowpages.com) for tanning salon and that zip code. If multiple tanning salons were identified, a list was generated, and one tanning salon was randomly selected. If a given zip code did not have a tanning salon, the next randomized zip code result was used. If a given tanning salon had a nonworking telephone number or was unreachable after 5 attempts, a different randomized tanning salon was chosen for that zip code.

Data collection was completed by 3 of us (M.S.W., B.B., and L.B.) between February 1, 2015, and April 30, 2016. Each data collector posed as a minor who was 1 year younger than the stated regulation for that state.⁴Figure 1 shows the regulations for each state,¹⁰ with more detailed descriptions listed in Table 1 according to the state-by-state comparison by the National Conference of State Legislatures.⁴ In the 16 states where more than one age-related legislation was present, such as a ban at one age and parental consent required at another age, the data collector assessed the younger age restriction. A telephone script was followed whereby the investigator stated that she desired to get a tan before leaving for an upcoming family vacation. The tanning employee was then asked about session costs and whether a parent needed to be present to consent for the tanning session. The full telephone script is shown in the eFigure in the Supplement. The employee’s response of whether the data collector was allowed to tan was recorded in a spreadsheet (Excel; Microsoft Corp). If the salon was noncompliant with the state legislation, the reason for noncompliance was also recorded.

The population of the city or village for each zip code was obtained using 2010 US census data. Populations less than 15 000 were considered rural. A tanning facility was classified as independent if only one location was listed on the tanning facility’s website and it was the only business listed when the facility name and state were typed into a Google search. Each state or territory was categorized into a specific region of the United States based on the US census definition of US regions.¹¹ Finally, each state or territory was categorized into those with legislation enacted between 2014 and 2016 and those with legislation enacted before 2014.

Statistical analyses were carried out using a statistical software package (SAS, version 9.4; SAS Institute Inc). χ² Test or Fisher exact test was used to compare the difference in compliance rates separately for population (<15 000 vs ≥15 000), regional location (West, Midwest, South, or Northeast), independent vs chain tanning salon, age group being regulated (≤15 vs ≥16 years), and time frame of legislation (before 2014 vs 2014-2016). Each of the above-mentioned statistical tests generated a 2-sided P value, and P < .05 represented a statistically significant difference in compliance rates.

A total of 427 tanning facilities were contacted in 42 states and the District of Columbia. Only a total of 7 UV tanning facilities were found in Hawaii. The characteristics of the tanning salons contacted are listed in Table 2. Overall noncompliance with state tanning legislation was 37.2% (159 of 427), and the most common reason for being coded as noncompliant was allowing tanning with parental consent at the banned age (32.1% [51 of 159]). Other reasons for noncompliance included allowing tanning without the required parental consent or accompaniment (27.7% [44 of 159]), allowing written parental consent only when parental accompaniment was required (19.5% [31 of 159]), banning tanning at the allowed age (11.3% [18 of 159]), allowing parental accompaniment at the banned age (5.0% [8 of 159]), allowing tanning without asking the minor’s age (3.1% [5 of 159]), and allowing tanning at the banned age (1.3% [2 of 159]).

Table 1 lists the noncompliance rates by state. Those 16 states with 2 or more types of tanning legislation (ie, including age bans and parental consent legislation) have a 50.0% (80 of 160) noncompliance rate with the restriction assessed (Table 3). That was inferior to the 27 states or territories with only 1 type of tanning legislation, which had a noncompliance rate of 29.6% (79 of 267). Only Illinois, New Hampshire, and Oregon had 100% compliance. Alabama had the worst compliance at 0%.

Table 3 lists stratified tanning salon compliance with state legislation. There were more noncompliant tanning salons in rural locations (45.5% [71 of 156]) compared with nonrural locations (32.5% [88 of 271]) (P = .009). There were more noncompliant tanning salons in the South (49.4% [79 of 160]) compared with any other region (30.0% [80 of 267]) (P = .001). There were more noncompliant tanning salons among independently owned tanning salons (43.9% [100 of 228]) compared with chain tanning salons (29.6% [59 of 199]) (P = .003). There were more noncompliant tanning salons in states or territories with laws governing younger minors (15 years and younger) (53.5% [91 of 170]) compared with those governing older minors (16 years and older) (26.5% [68 of 257]) (P < .001). There were more noncompliant tanning salons in states with more than one tanning regulation (50.0% [80 of 160]) compared with states with only one tanning regulation (29.6% [79 of 267]) (P < .001). States that banned all minors had better compliance than states with any other type of tanning legislation (78.1% [107 of 137] vs 55.5% [161 of 290], P < .001). Finally, the noncompliance of states that had more recent tanning legislation did not perform differently than those with longer-standing tanning legislation (38.8% [57 of 147] vs 36.4% [102 of 280], P = .67).

Tanning legislation is enacted to protect the public from cancer risk. This study assessed tanning salon compliance with state legislation in all 42 states and the District of Columbia that had legislation restricting tanning bed use in minors at the time of study completion. The study looked specifically at differences in compliance by community population, region of the United States, type of business (independent vs chain tanning salon), age group being regulated, the time elapsed since legislation was passed, and states with only one vs more than one tanning regulation. Our study suggests that more than one-third of tanning salons are noncompliant with legislation. Improved enforcement of tanning legislation is critical to decreasing the risks of skin cancer. In reviewing each state’s laws, most were silent on monitoring and enforcement. When mentioned (19 of 43), monitoring and enforcement was most often a responsibility given to local health departments (14 of 19). However, in one study¹² looking at tanning law enforcement of 22 metropolitan communities, approximately 32% of the city health departments assigned to monitor compliance did not inspect tanning facilities, and another 32% conducted inspections less than annually. Of the 43 states with tanning bans, only 20 laws mention specific fines, ranging from $50 up to $25 000 (most were in the $250-$1000 range). Eight laws state that failure to comply is a misdemeanor, and 5 state that the salon’s license or permit can be revoked or temporarily suspended. Still, even when violations were found, at least in one study¹² less than 50% of violators were penalized.

If each state was given a letter grade for performance (with A, ≥90% compliance; B, 80%-89% compliance; C, 70%-79% compliance; D, 60%-69% compliance; and F, <60% compliance), only 13 of 43 (30.2%) states or territories would make the A/B honor roll for compliance (Figure 2). Those states with only one type of tanning legislation performed better than those with at least 2 types of legislation. Remembering details of multiple tanning laws is perhaps difficult for tanning salon employees. A federal ban on tanning for anyone younger than 18 years might be easier for employees to remember and enforce. Furthermore, those states having tanning bans for minors younger than 18 years were significantly more compliant with legislation compared with states having any other type of tanning legislation. The only 3 states with 100% compliance (New Hampshire, Oregon, and Illinois) all have tanning bans for anyone younger than 18 years.

Because rural, southern, and independently owned US tanning salons were less compliant with state legislation, further targeted assessment of compliance with the law and public education may be necessary. It is unlikely that the education will come from the tanning industry. A previous study⁶ found that 61% of California tanning salons surveyed denied the dangers of UV tanning, and up to 17% claimed that indoor tanning was helpful by preventing future sunburns. Parents should also be better educated on the harmful effects of UV radiation because parental influence is one of the main factors leading to underage tanning.^13,14

Our study has several limitations. These encounters were scripted telephone calls instead of in-person encounters. It is possible that compliance rates would have been different with in-person encounters with actual minors. However, according to a 2006 study by Hurd et al,¹⁵ concordance between telephone-based indoor tanning compliance and face-to-face compliance was comparable. It is also possible that the employee triaging the telephone calls was not the final step in the vetting process and that additional screening processes more in compliance with the law would have been performed when a scheduled minor arrived for tanning. Included in the category of salons out of compliance with the law were salons that banned tanning at an allowable age. From a dermatologist’s perspective, this might be considered a good form of noncompliance. These salons perhaps wanted to uphold a safer standard than the law allows, which should be encouraged. Although our overall sample size for assessing US tanning compliance was good (n = 427), another limitation is our small sample size per state or territory (n = 10). However, when comparing our individual state compliance rates vs those previously reported in other studies, compliance rates were comparable for Wisconsin⁸ (80% vs 77%), Texas⁷ (80% vs 81%), and California⁶ (90% vs 77%).

Further studies are needed to assess compliance of all states with state regulations, including whether increased compliance correlates with decreased skin cancer incidence over time. A reliable method for monitoring and enforcing state legislation is also needed.

While most states in the United States have passed legislation regarding youth access to indoor tanning, our study demonstrates that tanning salon compliance with legislation remains a problem. The best compliance with the law was found in states with tanning bans for all minors. Rural locations, the southern United States, and independently owned tanning salons have the lowest rates of compliance, highlighting the need for more education and better law enforcement regarding state legislation and the harmful effects of UV indoor tanning.

Accepted for Publication: August 2, 2017.

Corresponding Author: Erik J. Stratman, MD, Department of Dermatology, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (stratman.erik@marshfieldclinic.org).

Correction: This article was corrected online December 6, 2017, for typographical errors in the Results section.

Published Online: October 25, 2017. doi:10.1001/jamadermatol.2017.3736

Author Contributions: Drs Williams and Stratman 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: Williams, Buhalog, Stratman.

Acquisition, analysis, or interpretation of data: Williams, Buhalog, Blumenthal.

Drafting of the manuscript: Williams, Buhalog, Stratman.

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

Obtained funding: Williams.

Administrative, technical, or material support: Williams.

Study supervision: Stratman.

Conflict of Interest Disclosures: None reported.