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
SPECIAL ARTICLE
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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
SPECIAL ARTICLE
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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
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
SPECIAL ARTICLE
PEDIATRICS Volume 131 Number 4 April 2013 773 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from
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
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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
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
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
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
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
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
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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
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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
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
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
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
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
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
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
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
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
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