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Study |

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

Robert P. Dellavalle, MD, PhD; Eva R. Parker, MD; Nancy Cersonsky, MD; Eric J. Hester, MD; Bragg Hemme, JD; Diane L. Burkhardt, JD; Alan K. Chen, JD; Lisa M. Schilling, MD
[+] Author Affiliations

From the Department of Veterans Affairs Medical Center (Dr Dellavalle), Departments of Dermatology (Drs Dellavalle, Parker, Cersonsky, and Hester), Preventive Medicine and Biometrics (Dr Dellavalle), and Medicine (Dr Schilling), University of Colorado School of Medicine, and University of Denver College of Law (Mss Hemme and Burkhardt and Mr Chen), Denver, Colo. The authors have no relevant financial interest in this article.


Arch Dermatol. 2003;139(4):443-448. doi:10.1001/archderm.139.4.443.
Text Size: A A A
Published online

Objective  To compare laws governing youth access to UV irradiation at indoor tanning facilities with laws governing youth access to tobacco.

Design  Tobacco and UV irradiation youth access laws were assessed via correspondence with public health offices and computerized legal searches of 6 industrialized nations with widely differing skin cancer incidence rates.

Setting  National, provincial, and state legal systems in Australia, Canada, France, New Zealand, the United Kingdom, and the United States.

Participants  Public health, legal, information science, and medical professionals and government and tanning industry representatives.

Main Outcome Measures  Statutes specifying age restrictions for the purchase of indoor tanning services or tobacco products.

Results  The 5 English-speaking countries with common law–based legal systems unilaterally prohibit youth access to tobacco but rarely limit youth access to UV irradiation from tanning salons. Only very limited regions in the United States and Canada prohibit youth access to indoor tanning facilities: Texas, Illinois, Wisconsin, and New Brunswick prohibit tanning salon use by minors younger than 13, 14, 16, and 18 years, respectively. In contrast, French law allows minors to purchase tobacco but prohibits those younger than 18 years from patronizing tanning salons.

Conclusions  Youth access laws governing indoor tanning display remarkable variety. Uniform indoor tanning youth access laws modeled on the example of tobacco youth access laws merit consideration.

Figures in this Article

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.811 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,1217 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.

Place holder to copy figure label and caption

A, Distribution of tobacco youth access laws: Red indicates areas where the purchase of tobacco by minors younger than a specified age is prohibited. Green indicates areas where tobacco purchase by minors is unrestricted. B, Distribution of UV irradiation youth access laws: Red indicates areas where the use of indoor tanning facilities by minors younger than a specified age is prohibited. Yellow indicates areas where written guardian consent or guardian accompaniment is required for the use of indoor tanning facilities by minors younger than a specified age. Green indicates areas where indoor tanning facility use by minors is not restricted.

Graphic Jump Location

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

Table Graphic Jump LocationTable 1. Age Restrictions on Tanning Bed Users

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.

Table Graphic Jump LocationTable 2. Recently Defeated Legislation Proposing Restrictions on Youth Access to Indoor UV Irradiation

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.

Not Available, 2002/2003 Looking Fit Tanning Fact Book. Available at:http://www.lookingfit.com/factbook/chapter1.html#The%20Growth%20of%20an%20IndustryAccessed February 7, 2003
Deveney  J Understanding customer base demographics. Sun Business. 2000;351- 53
Oliphant  JAForster  JLMcBride  CM The use of commercial tanning facilities by suburban Minnesota adolescents. Am J Public Health. 1994;84476- 478
Link to Article
Boldeman  CBeitner  HJansson  BNilsson  BUllen  H Sunbed use in relation to phenotype, erythema, sunscreen use and skin diseases: a questionnaire survey among Swedish adolescents. Br J Dermatol. 1996;135712- 716
Link to Article
Robinson  JKRademaker  AWSylvester  JACook  B Summer sun exposure: knowledge, attitudes, and behaviors of midwest adolescents. Prev Med. 1997;26364- 372
Link to Article
Cokkinides  VEWeinstock  MAO'Connell  MCThun  MJ Use of tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: prevalence and correlates. Pediatrics. 2002;1091124- 1130
Link to Article
Geller  ACColditz  GOliveria  S  et al.  Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics. 2002;1091009- 1014
Link to Article
Committee on Environmental Health, Ultraviolet light: a hazard to children. Pediatrics. 1999;104328- 333
Link to Article
Not Available, Ultraviolet radiation related exposures: broad spectrum ultraviolet (UV) radiation UVB UVA, UVC, solar radiation and exposure to sunlamps and sunbeds. US Dept of Health and Human Services,10th Report on Carcinogens 2002;Available at:http://ehis.niehs.nih.gov/roc/tenth/profiles/s183uvrr.pdfAccessed February 7, 2003
Not Available, Injuries associated with ultraviolet tanning devices—Wisconsin. MMWR Morb Mortal Wkly Rep. 1989;38333- 335
Karagas  RKStannard  VAMott  LASlattery  MJSpencer  SKWeinstock  MA Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 2002;94224- 226
Link to Article
Wang  SQSetlow  RBerwick  M  et al.  Ultraviolet A and melanoma: a review. J Am Acad Dermatol. 2001;44837- 846
Link to Article
Swerdlow  AJWeinstock  MA Do tanning lamps cause melanoma? an epidemiologic assessment. J Am Acad Dermatol. 1998;3889- 98
Link to Article
Whitmore  SEMorison  WLPotten  CSChadwick  C Tanning salon exposure and molecular alterations. J Am Acad Dermatol. 2001;44775- 780
Link to Article
Marks  R Skin cancer: childhood protection affords lifetime protection. Med J Aust. 1987;147475- 476
Weinstock  MAColditz  GAWillett  WC  et al.  Nonfamilial cutaneous melanoma incidence in women associated with sun exposure before 20 years of age. Pediatrics. 1989;84199- 204
Swerdlow  AJEnglish  JSMacKie  RM  et al.  Fluorescent lights, ultraviolet lamps, and risk of cutaneous melanoma. BMJ. 1988;297647- 650
Link to Article
Not Available, The Darker Side of Indoor Tanning: Skin Cancer, Eye Damage, Skin Aging, Allergic Reactions.  Rockville, Md US Public Health Service, US Dept of Health and Human Services1987;DHHS publication FDA 87-8270
Spencer  JMAmonette  RA Indoor tanning: risks, benefits, and future trends. J Am Acad Dermatol. 1995;33288- 298
Link to Article
Stern  RSWeinstein  MCBaker  SG Risk reduction for nonmelanoma skin cancer with childhood sunscreen use. Arch Dermatol. 1986;122537- 545
Link to Article
Khlat  MVail  AParkin  MGreen  A Mortality from melanoma in migrants to Australia: variation by age at arrival and duration of stay. Am J Epidemiol. 1992;1351103- 1113
Lim  HWCooper  K The health impact of solar radiation and prevention strategies: report of the environment council, American Academy of Dermatology. J Am Acad Dermatol. 1999;4181- 99
Link to Article
Friedman  LM A History of American Law. 2nd ed. New York, NY Simon & Schuster1985;560- 561
Woodhouse  BB "Who owns the child?": Meyer and Pierce and the child as property. Wm & Mary Law Rev. 1992;33 (995) 1059- 1069
Not Available, Not Available 42 USC §300x-26; 45 CFR §§96.122-96.1302000;
Fishman  JAAllison  HKnowles  SB  et al.  State laws on tobacco control—United States, 1998. MMWR CDC Surveill Summ. 1999;4821- 40
Not Available, Décre 97-617 du 30 mai 1997, Article 4. Available at:http://www.legifrance.gouv.fr/WAspad/RechercheSimpleLegi.jspAccessed February 7, 2003
Not Available, Not Available La Rev Stat Ann §40:10951992;
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Australian/New Zealand Standard, Solaria for cosmetic purposes. 2002;2635Available at:http://www.standards.com.aureference No. 2635. [A fee is charged to retrieve this article.]Accessed January 8, 2003
Sikes  RG The history of sun tanning. J Aesthetic Sci. 1998;16- 7
Rigel  DSFriedman  RJKopf  AW The incidence of malignant melanoma in the United States: issues as we approach the 21st century. J Am Acad Dermatol. 1996;34839- 847
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Gusfield  JR The social symbolism of smoking and health. Schaler  JASchaler  MEeds.Smoking: Who Has the Right? Amherst, NY Prometheus Books1998;240- 246
Reed  R Texas tackles "hot bed" tanning issue. Dermatol World. August2001;26
Fichtenberg  CMGlantz  SA Youth access interventions do not affect youth smoking. Pediatrics. 2002;1091088- 1092
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Livingood  WCWoodhouse  CDSayre  JJWludyka  P Impact study of tobacco possession law enforcement in Florida. Health Educ Behav. 2001;28733- 748
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Culley  CAMayer  JAEckhardt  L  et al.  Compliance with federal and state legislation by indoor tanning facilities in San Diego. J Am Acad Dermatol. 2001;4453- 60
Link to Article
Liptak  A Mother is jailed after children are sunburned. New York Times. August21 2002;A10
US Department of Transportation National Highway Traffic Safety Administration, Legislative Fact Sheet. Available at:http://www.nhtsa.dot.gov/people/injury/airbags/buckleplan/buckleup/legfact.htmlAccessed February 7, 2003
Nelson  DEBolen  JKresnow  M Trends in safety belt use by demographics and by type of state safety belt law, 1987 through 1993. Am J Public Health. 1998;88245- 249
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Buller  DBBorland  R Public education projects in skin cancer prevention: childcare, school and college-based. Clin Dermatol. 1998;16447- 459
Link to Article

Figures

Place holder to copy figure label and caption

A, Distribution of tobacco youth access laws: Red indicates areas where the purchase of tobacco by minors younger than a specified age is prohibited. Green indicates areas where tobacco purchase by minors is unrestricted. B, Distribution of UV irradiation youth access laws: Red indicates areas where the use of indoor tanning facilities by minors younger than a specified age is prohibited. Yellow indicates areas where written guardian consent or guardian accompaniment is required for the use of indoor tanning facilities by minors younger than a specified age. Green indicates areas where indoor tanning facility use by minors is not restricted.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Age Restrictions on Tanning Bed Users
Table Graphic Jump LocationTable 2. Recently Defeated Legislation Proposing Restrictions on Youth Access to Indoor UV Irradiation

References

Not Available, 2002/2003 Looking Fit Tanning Fact Book. Available at:http://www.lookingfit.com/factbook/chapter1.html#The%20Growth%20of%20an%20IndustryAccessed February 7, 2003
Deveney  J Understanding customer base demographics. Sun Business. 2000;351- 53
Oliphant  JAForster  JLMcBride  CM The use of commercial tanning facilities by suburban Minnesota adolescents. Am J Public Health. 1994;84476- 478
Link to Article
Boldeman  CBeitner  HJansson  BNilsson  BUllen  H Sunbed use in relation to phenotype, erythema, sunscreen use and skin diseases: a questionnaire survey among Swedish adolescents. Br J Dermatol. 1996;135712- 716
Link to Article
Robinson  JKRademaker  AWSylvester  JACook  B Summer sun exposure: knowledge, attitudes, and behaviors of midwest adolescents. Prev Med. 1997;26364- 372
Link to Article
Cokkinides  VEWeinstock  MAO'Connell  MCThun  MJ Use of tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: prevalence and correlates. Pediatrics. 2002;1091124- 1130
Link to Article
Geller  ACColditz  GOliveria  S  et al.  Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics. 2002;1091009- 1014
Link to Article
Committee on Environmental Health, Ultraviolet light: a hazard to children. Pediatrics. 1999;104328- 333
Link to Article
Not Available, Ultraviolet radiation related exposures: broad spectrum ultraviolet (UV) radiation UVB UVA, UVC, solar radiation and exposure to sunlamps and sunbeds. US Dept of Health and Human Services,10th Report on Carcinogens 2002;Available at:http://ehis.niehs.nih.gov/roc/tenth/profiles/s183uvrr.pdfAccessed February 7, 2003
Not Available, Injuries associated with ultraviolet tanning devices—Wisconsin. MMWR Morb Mortal Wkly Rep. 1989;38333- 335
Karagas  RKStannard  VAMott  LASlattery  MJSpencer  SKWeinstock  MA Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 2002;94224- 226
Link to Article
Wang  SQSetlow  RBerwick  M  et al.  Ultraviolet A and melanoma: a review. J Am Acad Dermatol. 2001;44837- 846
Link to Article
Swerdlow  AJWeinstock  MA Do tanning lamps cause melanoma? an epidemiologic assessment. J Am Acad Dermatol. 1998;3889- 98
Link to Article
Whitmore  SEMorison  WLPotten  CSChadwick  C Tanning salon exposure and molecular alterations. J Am Acad Dermatol. 2001;44775- 780
Link to Article
Marks  R Skin cancer: childhood protection affords lifetime protection. Med J Aust. 1987;147475- 476
Weinstock  MAColditz  GAWillett  WC  et al.  Nonfamilial cutaneous melanoma incidence in women associated with sun exposure before 20 years of age. Pediatrics. 1989;84199- 204
Swerdlow  AJEnglish  JSMacKie  RM  et al.  Fluorescent lights, ultraviolet lamps, and risk of cutaneous melanoma. BMJ. 1988;297647- 650
Link to Article
Not Available, The Darker Side of Indoor Tanning: Skin Cancer, Eye Damage, Skin Aging, Allergic Reactions.  Rockville, Md US Public Health Service, US Dept of Health and Human Services1987;DHHS publication FDA 87-8270
Spencer  JMAmonette  RA Indoor tanning: risks, benefits, and future trends. J Am Acad Dermatol. 1995;33288- 298
Link to Article
Stern  RSWeinstein  MCBaker  SG Risk reduction for nonmelanoma skin cancer with childhood sunscreen use. Arch Dermatol. 1986;122537- 545
Link to Article
Khlat  MVail  AParkin  MGreen  A Mortality from melanoma in migrants to Australia: variation by age at arrival and duration of stay. Am J Epidemiol. 1992;1351103- 1113
Lim  HWCooper  K The health impact of solar radiation and prevention strategies: report of the environment council, American Academy of Dermatology. J Am Acad Dermatol. 1999;4181- 99
Link to Article
Friedman  LM A History of American Law. 2nd ed. New York, NY Simon & Schuster1985;560- 561
Woodhouse  BB "Who owns the child?": Meyer and Pierce and the child as property. Wm & Mary Law Rev. 1992;33 (995) 1059- 1069
Not Available, Not Available 42 USC §300x-26; 45 CFR §§96.122-96.1302000;
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