Youth Access Laws:  In the Dark at the Tanning Parlor? FREE

THE NUMBER of minors using tanning devices is surprisingly large and increasing. The $5 billion tanning salon industry counts more than 2.3 million teenagers among its estimated North American consumer base of 28 million.^1- 2 Studies assessing indoor tanning by minors in the past decade confirm widespread use: In 1991, 34% of 1008 suburban Minnesota high school students reported using commercial tanning facilities (lifetime prevalence of 51% for girls and 15% for boys).³ Fifty-seven percent of 1252 Swedish students aged between 14 and 19 years reported sunbed use 4 or more times during the previous year.⁴ In the US Midwest, 12.5% of female 17- to 19-year-olds answering telephone questionnaires in 1994 reported using indoor tanning devices 6 or more times in the past year.⁵ In 1998, a US population-based telephone survey found that 10% of children aged 11 to 18 years reported using tanning sunlamps in the previous year.⁶ And in 1999, a large US cross-sectional study using self-reported questionnaires found nearly 10% of respondents aged 12 to 18 years reported using a tanning bed in the previous year.⁷

While teenagers may seek indoor tanning because tanned skin is portrayed socially as beautiful and healthy, indoor tanning equipment may cause cutaneous and ocular burns, immune system suppression, polymorphous light eruptions, and drug- and cosmetic-induced photosensitivity.^8- 11 A recent US case-control study has demonstrated a significant association of any use of tanning devices with increased skin cancer incidence: squamous cell carcinoma odds ratio (OR), 2.5 (95% confidence interval [CI], 1.7-3.8); basal cell carcinoma OR, 1.5 (95% CI, 1.1-2.1).¹¹ Tanning device use has also been implicated in increasing melanoma risk,^12- 17 despite methodological challenges encountered in associating tanning device use and melanoma.¹³ While the dangers of indoor UV irradiation and outdoor UV exposure are difficult to compare, indoor tanning readily produces DNA mutation and burns, and may involve equipment that emits levels of UV-A radiation up to 10 times higher than those occurring in natural sunlight.^14,18- 19 Since youth is an especially critical period during which UV irradiation increases skin cancer risk,^11,20- 21 altering the tanning behavior of minors is an important goal in disease prevention.^11,13,22

Laws protecting the health and safety of children reflect changing societal attitudes. As an example, child labor laws in the United States first emerged in the mid-19th century, but these laws were not widespread until the early 1900s and were not effectively enforced until the mid-20th century.^23- 24 The US regulation of tobacco sales to minors has similarly evolved, culminating with a 1992 federal law requiring each state to ban the sale of tobacco to minors as a condition for receiving federal grants for substance abuse prevention and treatment.²⁵ Pursuant to that law, all US states ban the sale of tobacco to minors.²⁶ Unlike indoor tanning youth access laws, tobacco youth access laws have been extensively studied and chronicled.²⁶ The aim of the present study was to assess youth access laws for indoor tanning and to compare these with tobacco youth access laws.

The search for youth access laws focused on English-speaking industrialized nations with common law–based legal systems and well-developed legal information networks but widely divergent skin cancer rates. The French legal system was included to illustrate the contrast that French youth access laws provide (Figure 1). Youth access laws were assessed via (1) computerized searches of Internet information sources and legal databases; (2) correspondence with regional health departments and ministries, professional societies, and tanning industry representatives; and (3) verifiable information canvassed from attendees of scientific meetings where preliminary search results were presented in poster format.

For the computerized search, we used the proprietary legal search engines LEXIS, WESTLAW, and CCINFOWEB; the Internet search engines Yahoo! and Google; and the terms "tanning," "sunbed," "solarium," "radiation," "tanning or ‘indoor tanning' w/s (minor or child or parent)," and "skin care." Legal information from government and other relevant Web sites was compiled independently by 4 of the authors and compared. Information was also requested from the health departments of all US states, Canadian provinces, and other organizations and individuals, including the American Academy of Dermatology, the British Association of Dermatologists, the Indoor Tanning Association, the North American Alliance of Tanning Salon Owners, International Smart Tan Network, law firms representing the tanning industry, and attendees of the 62nd Annual Meeting of the Society for Investigative Dermatology, May 9-12, 2001, Washington, DC, and the Sixth Annual Meeting of the Dermatoepidemiology Association, June 9-11, 2001, Noordwidjkerhout, the Netherlands, where preliminary legal search results were presented as posters. A list of Web sites used in the data collection appears at the end of this article. Accessibility to all Web sites was verified on February 7, 2003.

Computerized searches for information on enforcement plans for youth access indoor tanning regulations used the natural language (non-Boolean) function of WESTLAW for the terms "tanning parlors," "salons," "regulations," "minors," "youth access," "parental consent forms," "penalties," "enforcement," "sting operations," and "undercover operations." This search was done in the ALLNEWSPLUS database, the broadest available news database in WESTLAW, and repeated with Yahoo! and Google search engines. Statutes regarding tobacco youth access laws were accessed using the same search engines and the Boolean search phrase "(tobacco or smok!) w/s minor."

The purchase of tobacco products by minors is heavily restricted in all regions of the 5 English-speaking countries but not in France (Figure 1, A). Our search reconfirmed previous findings²⁶ that all 50 states in the United States and most regions of the other surveyed nations prohibit the purchase of tobacco products by those younger than 18 years. Purchasers of tobacco must be at least 16 years old in the United Kingdom and 19 in Alaska, Alabama, Utah, and the Canadian provinces of Ontario and British Columbia.

In contrast to tobacco youth access laws, only France and limited regions of the United States and Canada prohibit youth access to indoor tanning (Figure 1, B). Since 1997, France has prohibited the use of tanning facilities by those younger than 18 years.²⁷ In the United States, only 3 states, Wisconsin, Illinois, and Texas, prohibit tanning parlor use by those younger than 16, 14, and 13 years, respectively. Eighteen states and 3 counties within 2 additional states require written guardian consent for teenage minors of various ages to use indoor tanning facilities. Eight of the 18 states requiring guardian consent additionally require guardian accompaniment of children younger than either 14 or 16 years to the tanning facility (Table 1). In 2002, Tennessee enacted legislation requiring notarized guardian signatures on consent forms if parents are not present with the minor at the tanning facility. Higher consent standards are required of the medical profession. Medical treatment of those younger than 18 years with artificial UV irradiation for skin disease such as psoriasis or cutaneous T-cell lymphoma requires guardian consent for therapy in all US states except Louisiana.²⁸

Noncompliance with statutes governing youth access to indoor tanning is generally considered a misdemeanor punishable by fines up to $2000 and/or incarceration up to 60 days and may result in revocation of a tanning facility's license (see http://www.uchsc.edu/tanning/index.htm). Georgia and Texas impose the harshest criminal penalties, allowing for incarceration for up to 1 year for vendor noncompliance, while Texas and South Carolina allow the highest civil penalties, up to $25 000. No enforcement plans for indoor tanning youth access laws were found.

Only 1 province in Canada limits tanning facility access by minors: New Brunswick prohibits tanning facility use by those younger than 18 years (Figure 1, B; Table 1). The United Kindgom has no existing laws restricting minor access to tanning salons. Similarly, New Zealand and Australia have no restrictions on minors' access to tanning salons, and these countries have the highest rates of melanoma and nonmelanoma skin cancer of those surveyed (male age-adjusted melanoma incidence rate per 100 000 person-years: Australia, 40.5; New Zealand, 36.7; United States, 13.3; Canada, 8.2; France, 6.8; United Kingdom, 3.8).²⁹

The Australian Standard for Solaria recommends a minimum age of 18 years for tanning facility use without parental consent and a minimum age of 15 years with parental consent.³⁰ However, unlike youth access laws, these recommendations are voluntary and carry no penalties for noncompliance. Likewise, several European nations (Spain, Germany, and Sweden) and international organizations have adopted or are considering age limit recommendations for tanning device use, (eg, the European Society of Skin Cancer Prevention [http://www.euroskin.org], the International Commission on Nonionizing Radiation Protection [http://www.icnirp.de], the International Electrotechnical Commission [http://www.iec.ch], and the European Committee for Electrotechnical Standardization [http://www.cenelec.be]). See http://www.uchsc.edu/tanning/index.htm for legal updates and further details.

More than 100 years ago, unrevealing fashions and shade-seeking behavior routinely limited UV radiation exposure for most of the population. Many credit French fashion designer Coco Chanel for making tan skin chic in the 1920s.³¹ Throughout the 20th century, skin cancer incidence has increased, reflecting the popularity of revealing fashions and the increased sun-seeking behavior allowed by increased leisure time, outdoor activity, and travel.³²

Tobacco youth access restrictions are surprisingly old: by 1890, 26 US states had banned the sale of tobacco to minors.³³ By contrast, indoor tanning regulations are few and recent: in 2003 only 3 states ban younger subsets of minors from patronizing tanning salons despite widely accepted evidence that youth is the most critical period for UV exposure elevating skin cancer risk.⁸ Why several recent attempts to increase regulation of youth access to indoor tanning have met with severe compromise³⁴ and defeat (Table 2) deserves further analysis.

The disparity between indoor tanning and tobacco youth access laws might be explained by several factors: (1) the relatively small morbidity and mortality of tanning compared with smoking; (2) the less addictive nature of tanning compared with tobacco use; (3) the novelty of the tanning industry (starting in the 1970s); and (4) the lack of publicity of the carcinogenic properties of UV irradiation (eg, no US Surgeon General warning on the hazards of indoor tanning). Nonetheless many parallels between tobacco use and indoor tanning are evident: (1) Just as the tobacco industry had no standard on a minimum age for tobacco use until recently, the tanning industry has no standard on a minimum age for indoor tanning. (2) The tobacco and indoor tanning industries each represent major business interests that have derived financial benefits from allowing minors unlimited access to their carcinogenic products. (3) Just as the tobacco industry developed before science demonstrated the harm of smoking, the tanning industry also has evolved ahead of recent research showing harm. (4) Adverse effects of smoking and UV irradiation, including cancer, may emerge only after decades and in only a subset of users. Thus, multiple parallel factors may serve as barriers to the introduction of youth access regulations for these carcinogens.

While tobacco youth access laws remain controversial public health measures,³⁵ such laws have been reported to effectively aid reducing teen smoking up to 40%.³⁶ Youth access restrictions may prove even more effective for indoor tanning than for smoking for the following reasons: (1) Many underage smokers obtain cigarettes from parents, friends, and strangers or by theft, whereas similar social sources for indoor tanning do not exist. (2) Indoor tanning requires significantly more time and interaction between vendor and buyer than does purchasing tobacco, which leaves both parties to an indoor tanning transaction more exposed to law enforcement. (3) Professional tanning organizations may adopt policies to promote the integrity of the tanning industry by limiting youth access, while no similar professional tobacco vendor associations exist.

Under the law, minors require adult guidance in many areas of activity because they have yet to obtain full autonomy and decision-making capacity. Without restrictions, youth may accept the risk-taking behavior of tanning without weighing long-term health risks. At a minimum, uniform youth access restrictions on tobacco and indoor UV irradiation will reinforce public health education on these carcinogens, spur research on the efficacy of these measures, and call attention to the importance of improving compliance.³⁷ While youth access laws in isolation may fail, the addition of other proven carcinogen control strategies, including taxes, education, and media campaigns, may rapidly lower youth indoor tanning rates.

Our search uncovered no plans for enforcement of indoor tanning youth access laws. Enforcement decisions are generally not publicly reported and may be made on a case-by-case basis. State and local officials' decisions about how and when to enforce laws are largely subject to the discretion of the relevant officials whose decisions may in turn be constrained by budgetary and political implications. Nonetheless, the recent arrest and jailing of Eve Hibbits for allowing her children to become sunburned at an Ohio County Fair³⁸ may set precedent for the prosecution of those allowing or facilitating the UV burning of minors.

One criticism of youth access laws is that changes in behavior cannot be legislated. However, enacting youth access indoor tanning laws may spark societal changes that foster behavioral change. Such changes have been illustrated by the enactment of seat belt legislation. The rate of seat belt use in the United States, only 10% to 15% in the early 1980s, increased to approximately 70% following the enactment and enforcement of mandatory seat belt use laws and public education campaigns.^39- 40 This example demonstrates that legislation may influence cultural attitudes toward risk-taking behavior and effectively impact public health.

Societal attitudes toward tan skin, like societal attitudes toward smoking in airplanes and restaurants or drinking alcoholic beverages and driving, are malleable. Surveys in Australia have shown that the social appeal of tan skin decreased following skin cancer education and prevention campaigns.⁴¹ This fluctuation highlights the need to examine the efficacy of current youth access tanning restrictions where such laws exist. The present study provides a starting point for a regularly updated Internet reference on indoor tanning youth access laws. We invite submission to the authors of any missed indoor tanning youth access regulations, especially city, county, and other local ordinances. These submissions will be independently verified and posted at http://www.uchsc.edu/tanning/index.htm.

By limiting minors' access to tanning salons, we acknowledge that seeking UV radiation exposure is a carcinogenic behavior that should be carefully considered in this vulnerable population. Instituting uniform age restrictions will hinder and discourage casual, uninformed exposure to UV radiation by minors at tanning facilities and will serve as a small but important step toward reversing the rising tide of skin cancer and other UV radiation–associated disease.

In an effort to curb smoking among minors, the French Senate on February 11, 2003, approved a bill to ban the sale of cigarettes to children younger than 16 years.

Corresponding author and reprints: Robert P. Dellavalle, MD, PhD, University of Colorado Health Sciences Center, 4200 E Ninth Ave, Box B-153, Denver, CO 80262 (e-mail: robert.dellavalle@uchsc.edu).

Accepted for publication September 4, 2002.

This research was supported in part by the Department of Dermatology and the Cancer Center at the University of Colorado, Denver. Dr Dellavalle was supported by grant K-07 CA92550-01A1 from the National Cancer Institute, Bethesda, Md. Dr Hester was supported by grant T32 AR07411 from the National Institutes of Health, Bethesda, Md.

Preliminary data were presented as abstracts at the 62nd Annual Meeting of the Society for Investigative Dermatology, Washington, DC, May 9-12, 2001, and at the Sixth Annual Meeting of the Dermatoepidemiology Association, Noordwidjkerhout, the Netherlands, June 9-11, 2001.

We thank J. Carriere, JD; Helene Cole, MD; Katheryn Kennedy, PhD; J. Kuntzman, MLS; Joseph Morelli, MD; Mary Mauck, BA; David Norris, MD; Steven Parker, MBA; Allan Prochazka, MD; Kemp Weston, BA; William Weston, MD; and the University of Alberta John A. Weir Memorial Law Library and the University of Colorado Denison Memorial Library staffs for assistance with this work.