Unlimited and Unrestricted access to ultraviolet radiation: A case for effective state regulation over the indoor tanning industry

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Unlimited and Unrestricted access to ultraviolet
radiation A case for effective state regulation
over the indoor tanning industry

• Meghana Desai Aruru, PhD (Candidate), MBA,
  B.S.Pharm
• J.Warren Salmon, PhD
• Dept. Of Pharmacy Administration
• University of Illinois at Chicago
• maruru1_at_uic.edu

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Agenda

• Introduction
• Tanning practices
• Epidemiology of UV radiation on skin
• Fitzpatrick skin type classification
• Indoor Tanning Industry
• Policies pertaining to indoor tanning
• Discussion Questions

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Introduction

• UV tanning outdoors (sun) indoors (tanning
  units)
• Prevalence of indoor tanning is defined
  variously as any use in the past 6 or 12 months
  or frequent use in the past 12 months
• NCI Skin cancer most common form of cancer in
  U.S, diagnosed in more than 1.5 million Americans
  each year
• Increasing incidence of melanoma and non-melanoma
  skin cancers
• 2005 59,580 melanoma cases, 7,770 deaths
• 2006 62,190 melanoma cases, 7,910 deaths
  (estimated)
• SEER statistics - an average of 18.8 life-years
  lost per melanoma death. Melanomas addressed in
  Healthy People 2010, growing concern in AMA, WHO,
  AAD

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UV Radiation

• 200 nm 280nm
  320nm 400nm
• UVC UVB
  UVA (absorbed by ozone) (highly
  carcinogenic) (weakly carcinogenic)
• Acute Chronic effects from UV radiation
• Short term itching, nausea, pruritis, xerosis
• Long term - polymorphous light eruption,
  disseminated superficial actinic
  porokeratosis, mid-dermal electrolysis and
  actinic granulomas, melanomas, basal and
  squamous cell carcinomas
• Pre-existing photosensitivity in Lupus
  Erythmatosus, Polymorphous Light Eruption,
  Porphyria, and Rosacea significantly
  exacerbated by exposure to indoor tanning

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Emergence of tanning

• 1930s 40s Medical profession encouraged sun
  exposure as benefit to children
• 1948 First reported studies of vitiligo with
  oral topical psoralen
• Development of tan for cosmetic purposes
  French designer Coco Chanel
• 1970s Development of UVA beds for medicinal
  purposes
• Commercialization soon after with formation of
  the Indoor Tanning Association

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Skin cancers

• Melanoma in U.S
• Incidence rates rising by 4-8 each year
• Lifetime incidence is 1/71
• 3 of all cancers
• 1 of all cancer deaths
• Most common cause of death in women 30-39 years

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Skin Cancers - Melanomas
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Skin cancers - Melanomas

• Risk factors
• Family history
• Red/Blond hair
• Ample UV exposure (freckling on upper back,
  history of 3 or more sunburns before age 20, 3 or
  more outdoor jobs before age 20)
• Actinic keratosis
• Skin types I II
• Advanced age
• Atypical or congenital nevi

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Skin types

• Fitzpatricks classification 1977
• SED sub erythemal dose

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Skin type assessment

• Sun sensitivity or skin type remains constant
  during a lifetime
• Self assessment by individual tanners
• Assessment by low-wage, insufficiently trained
  tanning salon operators

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Indoor Tanning Association

• Total Number of Professional Indoor Tanning
  Facility Businesses 25,000
• Total Number of Professional Tanning Business
  Employees 160,000
• Total Professional Indoor Tanning Facility
  Customer Base 30 million
• Total Revenues Professional Indoor Tanning
  Facilities 5 billion

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Indoor Tanning Industry

• Misleading advertisements /or falsified
  messages
• Promoting UV protection through indoor tanning
  (lack of sufficient epidemiological evidence)
• Promotion of health benefits through Vitamin D
  production
• Promotion of trade-offs of certain internal
  cancers
• Stand against sunscreens

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Indoor Tanning Industry

• Significant advertising promotion to students
  
• Formed a Political Action Committee (PAC) to
  prevent ban on under-18 tanning

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Indoor Tanning Industry

• Tanning salon operator education
• Through 2 private institutions National tanning
  Training Institute (NTTI) and International Smart
  Tan Network (ISTN).
• No training for skin typing
• No training for radiation related burns and/or
  emergency procedures
• No demonstration of equipment handling

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Indoor Tanning
Source www.cartoonstock.com
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Tanning Salon Operators
Source www.cartoonstock.com
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Regulation Legislation

• FDA regulates equipment, adherence to
  performance standards, warning signs (FDA, 21 CFR
  Ch.1 1040.20)
• Regulation since 1979 Federal standards adopted
  to protect customers from eye and skin injuries
• 1985 Amendments by allowing longer exposure
  times for UVA emitting lamps
• 1986 Policy letter published on recommended
  exposure schedules
• Currently no regulation or monitoring of
  exposure times of patrons, no requirements for
  maintaining much information

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Regulation Legislation

• FTC prohibits deceptive advertising
• Individual states governance

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Screening

• Differences of opinions
• AAD, ACPM regular screening
• IOM, NCI insufficient evidence for screening
• USPSTF, CTF screening at-risk population
• Early detection of melanomas High 5-year
  survival rate
• External visible cancer with known risk factors
  

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Discussion

• According to Sharon A. Miller at the FDAs Center
  for Devices and radiological Health
• FDA does not recommend the use of indoor tanning
  equipment
• Comments
• - FDA does not regulate prevalence of indoor
  tanning
• - Currently no legislation protecting minors
  explicitly
• - No safeguards in place to protect the general
  tanning population
• - No requirements for exposure schedules or
  monitoring of UV radiation sessions in tanning
  salons

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Discussion

• Significant efforts by AAD, WHO, AMA to ban
  under-18 tanning
• Involving health professionals to detect
  melanomas and other skin cancers
• Regulation over exposure schedules with mandated
  record keeping
• Risk communication to adolescents immediate
  perceived benefits versus long term health issues
• Development of melanomas at later ages Medicare
  burden

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Conclusion

• UV exposure presents a significant and serious
  public health problem
• State health departments should mandate cancer
  risk reduction
• Need enforceable state regulatory safeguards in
  place
• Consumer awareness alone does not change tanning
  behaviors

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Conclusion

• Under-18 adolescents typically do not understand
  risk-benefit tradeoffs
• Concern about additive effects from both indoor
  outdoor tanning from studies
• Concern about proposed tanning addictions
• Need for also stepping up oversight by FDA FTC
• All suggestions are reasonable and not overly
  burdensome

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Conclusion

• Increasing vigilance by state health departments
  over indoor tanning activities including monetary
  penalties
• Monitoring tanning salon operator training to
  include in depth understanding of skin cancers in
  relation to UV radiation
• Public Health commitment required for best course
  of action

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Thank You