Indoor tanning: risks, benefits, and future trends

Ultraviolet Radiation Exposure: Public Health Concerns

The North American public maintains an attitude that equates the acquisition of a suntan with health. However, prolonged exposure to ultraviolet radiation from the sun can lead to sunburn, premature skin aging, immunosuppression, and skin cancer. Misconceptions about the risks of tanning beds and the effectiveness of sunscreens are common. The public must be better informed about the importance of and the need for effective sun protection by means of clothing and hats, the proper use of sunscreen, and the avoidance of prolonged sun exposure during the time of maximal solar insolation.

Banning children and youth younger than 18 years of age from commercial tanning facilities

Cutaneous malignant melanoma has increased more than three-fold in the past 35 years. Because damage is cumulative, exposure to ultraviolet radiation early in life elevates a risk that is increased further as individuals use artificial sources of ultraviolet radiation. The full impact and scope of damage caused by year-round indoor tanning may take years to appreciate given the long latency period for most skin cancers. Teenagers are frequent visitors to tanning parlours, with girls being more frequent and sustained users. The tanning industry disputes the World Health Organization's and the International Agency for Research on Cancer's classification of their product as a Class 1 physical carcinogen. Tanning parlours have sought to establish and maintain a client-base among teenagers. Consequently, the Canadian Paediatric Society is joining other prominent health organizations in support of a ban on the use of commercial tanning facilities by Canadian children and youth younger than 18 years of age.

Geography, facilities, and promotional strategies used to encourage indoor tanning in New York City

There is emerging evidence for the relationship between indoor tanning and melanoma. Eighty-five indoor tanning facilities in New York City were observed to determine number of tanning machines, pricing, promotions, products, and hours. Census data by zip code was used to determine population density, gender, race, age, percent living in poverty, percent unemployed, and percent college educated of areas in which tanning facilities were located. Pricing varied by the type of machine, number of sessions purchased, and single versus bundled sessions. Facilities were located in areas that had greater population density and slightly greater median age. Compared with the zip code areas with no facilities, those with tanning facilities had a higher proportion of white residents; a lower proportion of residents living in poverty and unemployed; and a higher proportion of residents with a college education. Our data suggest that the strategic location of facilities and promotions used in NYC seek to maximize patronage by those with comparatively high levels of income and education and who may be more influenced by the social desirability of artificial tanning. Long-term interventions aimed at changing social norms regarding tan skin are needed.

Ultraviolet radiation and skin cancer

Skin cancer is the most common type of cancer in fair-skinned populations in many parts of the world. The incidence, morbidity and mortality rates of skin cancers are increasing and, therefore, pose a significant public health concern. Ultraviolet radiation (UVR) is the major etiologic agent in the development of skin cancers. UVR causes DNA damage and genetic mutations, which subsequently lead to skin cancer. A clearer understanding of UVR is crucial in the prevention of skin cancer. This article reviews UVR, its damaging effects on the skin and its relationship to UV immunosuppression and skin cancer. Several factors influence the amount of UVR reaching the earth's surface, including ozone depletion, UV light elevation, latitude, altitude, and weather conditions. The current treatment modalities utilizing UVR (i.e. phototherapy) can also predispose to skin cancers. Unnecessary exposure to the sun and artificial UVR (tanning lamps) are important personal attributable risks. This article aims to provide a comprehensive overview of skin cancer with an emphasis on carefully evaluated statistics, the epidemiology of UVR-induced skin cancers, incidence rates, risk factors, and preventative behaviors & strategies, including personal behavioral modifications and public educational initiatives.

Skin cancer: knowledge, behaviors, and attitudes of college students

OBJECTIVES

Knowledge, attitudes, and behaviors of college students regarding melanoma and skin protection were examined.

METHODS

We surveyed 492 students at a mid-sized southern university. The Melanoma Risk Behavior Survey was administered in lecture classes.

RESULTS

Mean knowledge score was 10.6 ± 3.8 (24 questions). A majority of participants knew that sun exposure increases the risk for skin cancer; however, only 29% correctly identified behaviors that reduce this risk. Mean attitude score was 5.26 ± 2.73 (11 questions). Sixty-nine percent agreed that all people should take precautions against skin cancer; however, only 51% believed they themselves should practice sun safe behaviors. Mean behavior score was 1.29 ± 1.22 (9 possible). Only 3.1% reported avoiding the sun during peak hours, and only 5.1% regularly use sunscreen when exposed to the sun.

CONCLUSION

Campus programs for increasing awareness of skin cancer risk are warranted. Changing attitudes and behaviors regarding exposure and protective measures is increasingly important.

Defining the patient at high risk for melanoma

In this practical review, we aim to help clinicians identify patients who are at significant risk of developing malignant melanoma. Universal screening is challenging, thus it is important to effectively single out patients who have a high risk of developing the disease. We provide a summary of pertinent questions to review when taking the patient's history, point out the phenotypic features to note during skin examination, and suggest risk stratification as a means to plan initial and long-term surveillance strategy. We mention personal and family history of melanoma as prime risk factors for melanoma, yet the review also focuses on the patient who has no history of melanoma, either in himself or his family, and the proper ways to evaluate his likelihood of developing the disease.

Comparison of advertising strategies between the indoor tanning and tobacco industries

The indoor tanning industry is large and continues to grow, with 2007 domestic sales in excess of $5 billion. Advertising is central to shaping the consumer's perception of indoor tanning as well as driving industry demand. This article aims to identify key drivers of consumer appeal by comparing tanning advertising strategies to those used by tobacco marketers. Tobacco advertising was selected as a reference framework because it is both well documented and designed to promote a product with known health hazards. Two thousand advertisements from 4 large tobacco advertisement databases were analyzed for type of advertisement strategy used, and 4 advertising method categories were devised to incorporate the maximum number of advertisements reviewed. Subsequently, contemporary tanning advertisements were collected from industry magazines and salon websites and evaluated relative to the identified strategy profiles. Both industries have relied on similar advertising strategies, including mitigating health concerns, appealing to a sense of social acceptance, emphasizing psychotropic effects, and targeting specific population segments. This examination is a small observational study, which was conducted without rigorous statistical analysis, and which is limited both by the number of advertisements and by advertising strategies examined. Given the strong parallels between tobacco and tanning advertising methodologies, further consumer education and investigation into the public health risks of indoor tanning is needed.

Lifestyle Interventions in the Prevention and Treatment of Cancer

Despite evidence that cancer death rates in the United States are declining, the absolute number of new cancers and cancer deaths continues to increase, and there is clear evidence that certain human behaviors are influencing these increases. The 4 major factors of lifestyle that continue to be causally related to certain cancers—tobacco use, an unhealthy diet, inadequate exercise, and excessive exposure to ultraviolet radiation—are each independently important in their effects on the genetic and molecular processes that result in the malignant transformation of human cells. There is both irrefutable and otherwise strong evidence that 4 common cancers that occur in the United States—lung cancer, colon/rectal cancer, breast cancer, and prostate cancer—and a less common cancer, malignant melanoma, have etiologic factors that are lifestyle based and therefore controllable through alterations in human behavior. These cancers and the evidence that lifestyle is important in the causation and/or prevention of the disease are the subjects of this review.

Environmental dermatology in childhood: photosensitivity

Recently, sunlight-induced damage of healthy human skin, including skin malignancies and a large scale of photodermatoses representing a diverse group of diseases, have increased in childhood as a result of unfavorable environmental changes. This article yields an overview of the diagnosis, the clinical features and the treatment of these conditions and disorders and also reveals perspectives. Some diseases are more frequent in the pediatric population than in adulthood, whereas others heal spontaneously during adolescence and vice versa. The majority of cases are idiopathic photodermatoses, mainly polymorphic light eruption. Photosensitivity may be an early symptom of genetic disorders, such as porphyria, or very rare genophotodermatoses. Photosensitivity, secondary to topical or systemic external agents as well as photoexacerbated dermatoses, is not so frequent in childhood. Effective photoprotection is crucial.

Sun exposure and vitamin D sufficiency

Ultraviolet radiation is a carcinogen that also compromises skin appearance and function. Because the ultraviolet action spectra for DNA damage, skin cancer, and vitamin D(3) photosynthesis are identical and vitamin D is readily available from oral supplements, why has sun protection become controversial? First, the media and, apparently, some researchers are hungry for a new message. Second, the controversy is fueled by a powerful special interest group: the tanning industry. This industry does not target the frail elderly or inner-city ethnic minorities, groups for whom evidence of vitamin D(3) insufficiency is strongest, but rather fair-skinned teenagers and young adults, who are at highest risk of ultraviolet photodamage. Third, evolution does not keep pace with civilization. When nature gave humans the appealing capacity for cutaneous vitamin D(3) photosynthesis, life expectancy was <40 y; long-term photodamage was not a concern; and vitamin D(3) deficiency, with its resulting skeletal abnormalities (rickets), was likely to be fatal in early life. In the 21st century, life expectancy approaches 80 y in developed countries, vitamin D(3) is available at the corner store, and the lifetime risk of skin cancer is 1 in 3 among white Americans. Medical and regulatory groups should avoid poorly reasoned, sensationalistic recommendations regarding unprotected ultraviolet exposure. Instead, they should rigorously explore possible cause-and-effect relations between vitamin D(3) status and specific diseases while advocating the safest possible means of ensuring vitamin D(3) sufficiency.

Trends in UV irradiance of tanning devices in Norway: 1983-2005

Indoor tanning increases skin cancer risk, but the importance of different parts of the UV spectrum is unclear. We assessed irradiance of tanning devices in Norway for the period 1983-2005. Since 1983, all tanning models needed approval before being sold or used. UV Type 3 limits were valid from late 1992 (<0.15 W m(-2) for CIE-weighted, i.e. erythemally weighted, short and long wave irradiances). We analyzed data from 90% of the approved tanning models (n = 446 models) and two large inspection surveys in 1998/1999 and 2003 (n = 1,341 tanning devices). Mean CIE-weighted short wave irradiance of approved models increased from 0.050 W m(-2) (95% confidence interval [CI] 0.045-0.055) in 1983-1992 to 0.101 W m(-2) (95% CI 0.098-0.105) in 1993-2005, and mean long wave from 0.091 W m(-2) (95% CI 0.088-0.095) to 0.112 W m(-2) (95% CI 0.109-0.115), respectively. Inspection surveys revealed short wave irradiances much higher than that approved. In 1998-1999, only 28% (293/1034) of the devices were equipped with correct sunlamps and only 1 out of 130 inspected establishments fulfilled all requirements. In 2003, corresponding numbers were 59% (180/307) of devices and 2 out of 52 establishments. Mean short and long wave irradiances of the inspected tanning devices in 2003 were 1.5 and 3.5 times, respectively, higher than the irradiance of natural summer sun in Oslo. In conclusion, the short wave irradiance has increased in indoor tanning devices in Norway over the last 20 years. Due to the high long wave irradiance throughout this period, the percentage of short wave irradiance was much lower than for natural sun.

Exposure to sunlamps, tanning beds, and melanoma risk

OBJECTIVE

To estimate the separate effects of sunlamp and tanning bed device use on melanoma risk.

METHODS

Population-based case-control study of 423 cases of melanoma and 678 controls in the state of New Hampshire. Exposure data, including sunlamp and tanning bed use, were collected by telephone interview. Associations were evaluated using logistic regression analyses.

RESULTS

About 17% of participants ever used a sunlamp, and most use (89%) occurred before 1980. The OR was 1.39 (95% CI 1.00-1.96) for ever using a sunlamp, 1.23 (95% CI 0.81-1.88) for those starting sunlamp use <20 years, and 1.71 (95% CI 1.00-2.92) for those starting >/=20 years. Data suggested increasing risk with number of sunlamp uses and with duration of use (tests of trend p = 0.02). The overall prevalence of tanning bed use was 22% and most use (83%) occurred after 1980. The OR was 1.14 (95% CI 0.80-1.61) for ever using a tanning bed; there was no evidence that risk increased with frequency or duration of use. The OR was 1.96 (95% CI 1.06-3.61) for having used both devices.

CONCLUSION

Results suggest a modest association between sunlamp use and melanoma risk, and increasing risk with greater frequency and duration of use. No association with tanning bed use was found, but sufficient lag time may not have elapsed to assess a potential effect.

Vitamin D--an emerging issue in skin cancer control. Implications for public health practice based on the Australian experience

Over recent years, the evidence has been accumulating that vitamin D has a positive impact on our health. This is likely to have an impact on the future of our public health advice related to skin cancer prevention. This paper explores, from a public health perspective based on Australian experience, how skin cancer prevention messages need to be managed in light of new information about vitamin D and in particular, the times when sun protection advice should be provided. Conclusions are drawn in relation to how the vitamin D message can be complementary to the sun protection message and explores what health practitioners should do in light of artificial tanning sunbeds being a potential source of vitamin D.

Sun protection and Vitamin D: three dimensions of obfuscation

Ultraviolet (UV) radiation is a proven carcinogen, responsible for more than half of all human malignancies. It also compromises skin appearance and function. Since the UV action spectra for DNA damage, skin cancer and Vitamin D(3) (vit D) photosynthesis are identical and vit D is readily available from oral supplements, why has sun protection become controversial, now that some data suggest conventionally "sufficient" levels of vit D may be less than optimal for at least some population groups? First, the media and apparently some researchers are hungry for a new message. Nevertheless, after 50 years, UV exposure is still a major avoidable health hazard. Second, the controversy is fueled by a powerful special interest group: the indoor tanning industry. They target not the frail elderly or inner-city ethnic minorities, groups for whom evidence of vit D insufficiency is strongest, but rather fair-skinned teenagers and young adults, those at highest risk of UV photodamage. Third, evolution does not keep pace with civilization. When nature gave man the appealing capacity for vit D photosynthesis, the expected lifespan was far less than 40 years. Long-term photodamage was not a concern, and vit D was not available at the corner store. The medical community should avoid sensationalism and instead rigorously explore possible cause-and-effect relationships between vit D status and specific diseases while advocating the safest possible means of assuring vit D sufficiency.

Measuring the stringency of states' indoor tanning regulations: instrument development and outcomes

OBJECTIVES

We sought to describe the development of an instrument to quantify the stringency of state indoor tanning legislation in the United States, and the instrument's psychometric properties. The instrument was then used to rate the stringency of state laws.

METHODS

A 35-item instrument was developed. An overall stringency measure and 9 stringency subscales were developed, including one measuring minors' access to indoor tanning. Stringency measures showed good internal consistency and interrater reliability.

RESULTS

In all, 55% of the 50 states and the District of Columbia had any indoor tanning law, and 41% had any law addressing minors' access. Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island had high overall stringency scores, and Texas and New Hampshire were the most restrictive with regard to minors' access.

LIMITATIONS

Measurement of actual enforcement of the laws was not included in this study.

CONCLUSIONS

The instrument appears to be an easy-to-use, reliable, and valid methodology. Application of the instrument to actual laws showed that, in general, state laws are relatively weak, although there was considerable variability by state.

Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States)

OBJECTIVE

To examine the association between tanning bed use and weight concerns, health risk behaviors, and peer influence.

METHODS

The Growing Up Today Study (GUTS) is an ongoing prospective cohort study of adolescents established in 1996. In 1999, a total of 6,373 adolescent females ages 12-18 (offspring of participants in the Nurses Health Study 2) completed the survey.

RESULTS

Almost nine percent (8.6%) of the adolescent girls had used a tanning bed 1-9 times and an additional 5.4% had used tanning beds at least 10 times in the past year (frequent users). Logistic regression models revealed that frequent tanning bed use was associated with being highly concerned about weight (OR = 1.5, 95%CI = 1.1, 2.0), frequently dieting to lose weight (OR = 1.5, 95%CI = 1.1, 2.0), using laxatives or vomiting to control weight (OR = 3.6; 95%CI = 2.2-5.8), having friends who placed a lot of importance on being thin (OR = 2.6; 95%CI = 1.3-5.1), smoking cigarettes (OR=1.7, 95%CI = 1.1, 2.6), binge drinking (OR = 2.1, 95%CI = 1.3, 3.1), using recreational drugs (OR = 3.0; 95%CI = 2.4, 3.8), and trying to look like females in the media (sometimes/pretty much: OR = 1.3, 95%CI = 1.0, 1.8).

CONCLUSION

Frequent tanning bed use among adolescent females is associated with a range of health risk behaviors. This effect may be mediated by peer influence and a desire to look like other females in the media. Multi-pronged approaches, particularly those that target attitudes of young females, are needed to combat increased use of tanning beds.

Do adolescent indoor tanners exhibit dependency?

BACKGROUND

Indoor tanning is a common adolescent risk behavior that has been hypothesized to be motivated and maintained by the mood-altering effects of ultraviolet light.

OBJECTIVE

Our purpose was to explore heretofore anecdotal reports that indoor tanning leads to dependency.

METHODS

A telephone interview was conducted among 1275 adolescents, ages 14 to 17 years. Self-reported difficulty in quitting indoor tanning was assessed among 267 adolescents (20.9% of total) who tanned indoors more than once in the previous year in relation to age of initiation, frequency of use, and positive or negative consequences of the practice.

RESULTS

Difficulty in quitting was more likely with younger age at initiation (age 13 years or younger vs ages 16 to 17; odds ratio = 4.3, 95% confidence interval 1.3-14.7) and higher frequency of use (P = .009), even after accounting for positive or negative consequences of indoor tanning and other demographic characteristics.

LIMITATIONS

This was a cross-sectional study design with a limited outcome measure.

CONCLUSION

Although preliminary, our findings for age at initiation and frequency of use in relation to difficulty in quitting indoor tanning are consistent with other potentially addictive behaviors taken up during adolescence.

Reduction of the UV burden to indoor tanners through new exposure schedules: a pilot study

BACKGROUND

The development of new pigmentation (tan) in human skin after UV exposure requires several days. Once it is developed, the tan can last for weeks. Current recommendations for tanning exposure schedules in the USA (FDA Letter to Manufacturers: Policy on maximum timer interval and exposure schedule for sunlamps, August 21, 1986) allow exposures three times per week for the development of a tan, and one to two times per week for maintenance exposures. However, this policy is often interpreted in the indoor tanning industry as allowing three exposures per week on a continuous basis. We believe that the reduction of the recommended cumulative dose to indoor tanners should be explored. Two approaches for achieving this are (1) decreasing the number of exposures and (2) increasing the time interval between exposures. To explore such changes, we conducted a pilot study.

METHODS

The pilot study involved three exposure schedules (evaluated on each of six subjects) that evolved throughout the course of the study. Digital photography, visual assessment and diffuse reflectance spectrometry were used to assess skin color changes. The six pilot subjects were studied for 8-18 weeks. The changes in skin color obtained through the use of the different exposure schedules were compared with changes reported by Caswell (Caswell M, The kinetics of the tanning response to tanning bed exposures, Photodermatol Photoimmunol Photomed 2000: 16: 10-14) who used schedules based on current recommendations.

RESULTS

Two out of the three experimental schedules produced tans comparable with those reported by Caswell. In these two schedules, cumulative doses were a factor of 2-3 below doses from current schedules.

CONCLUSION

The UV burden to indoor tanners can be substantially reduced without compromising the cosmetic effect. These results need to be confirmed in a larger study.

The indoor UV tanning industry: A review of skin cancer risk, health benefit claims, and regulation

BACKGROUND

Nearly 30 million people tan indoors in the United States annually, including 2.3 million adolescents. Despite increased evidence on the dangers of artificial UV radiation, the popularity of indoor tanning is growing.

OBJECTIVES

We aim to assess the following 3 entities: (1) the association of indoor tanning with skin cancer; (2) statements regarding the health benefits of indoor tanning, especially regarding the production of vitamin D; and (3) current regulation of the tanning industry in the United States.

METHODS

We conducted a narrative review of the literature.

RESULTS

Indoor tanning poses great risks. Studies support the role of artificial UV radiation in cutaneous carcinogenesis. Despite claims by the tanning industry, artificial tanning is not a safe or necessary way to increase systemic vitamin D levels. The National Institutes of Health and the World Health Organization have acknowledged the risks of indoor tanning. Nonetheless, regulations limiting tanning in the United States are surprisingly sparse.

LIMITATIONS

Systematic review of the literature was not performed.

CONCLUSIONS

Health care providers must increase efforts to warn and educate the public and government about the dangers of UV radiation.

Indoor UV tanning operator opinion regarding youth access: an electronic survey

BACKGROUND

Adolescents frequently use indoor tanning facilities, but little is known about tanning facility operator opinions regarding this use. Objective To assess indoor tanning operator attitudes and stated practices regarding youth access.

METHODS

We electronically surveyed 89 indoor tanning facilities and 130 spas with active e-mail addresses.

RESULTS

The survey response rate was 21% for both indoor tanning facilities (19/89) and spas (27/130). Most tanning operators (92%) felt that a client can be too young to receive indoor tanning, and most felt that written parental permission should be required (80%). Most facilities required adult accompaniment (92%), and most operators had discouraged a customer from receiving indoor tanning based on age (77%). The reported age of the youngest patron receiving indoor tanning ranged from 5 to 21 years.

CONCLUSION

Our sample of indoor tanning facility operators believed that minimum age and parental consent regulations for indoor tanning should be required.

Indoor tanning by adolescents: prevalence, practices and policies

Despite known acute and chronic health effects from the use of indoor tanning, including the potential for all forms of skin cancer, the practice is popular in the United States (US) and Europe. A review of the scientific literature that examines adolescents and indoor tanning use was undertaken, summarising what is known about prevalence and practices among adolescents, characteristics associated with adolescent use, and policies that regulate adolescent access to indoor tanning facilities. The prevalence of indoor tanning is consistently found to be higher among girls than boys and to increase with age in both Europe and the US. An examination of other demographic characteristics, skin cancer risk factors, knowledge, attitudes and social factors points to higher prevalence of the behaviour among adolescents with positive attitudes towards tans and whose friends or parents also tan indoors. Adolescent access to indoor tanning is rarely regulated in the US or Europe, and where regulations exist, business compliance is low. In addition, businesses actively market their product to adolescents as they organise to limit further regulations prohibiting adolescent access. Pricing, licensure, advertising restrictions and media campaigns, in combination with adolescent-targeted interventions, are possible strategies that could be tested for their effectiveness to reduce adolescent indoor tanning use. Harm reduction policies, such as eye protection, that reduce risk for adolescents who choose to tan indoors, are also important.

The evolution of current medical and popular attitudes toward ultraviolet light exposure: part 3

In the 1930s, attitudes toward ultraviolet (UV) light exposure began to change significantly within the medical profession. UV radiation had been promoted as healthful since the century's start, and particularly after the discovery of its role in vitamin-D metabolism. Increasingly, however, attention would focus on the risks of UV light exposure from sunlamps and sunbathing. During this time, the American Medical Association established guidelines for the approval of UV lamps and the appropriate therapeutic uses of phototherapy. The landmark experiments of Findlay and other researchers, in which malignant skin tumors were induced in rodents after exposure to UV lamps or sunlight, would lead to widespread recognition of the carcinogenicity of UV radiation. The role of sunlight in the etiology of skin cancer was increasingly mentioned in articles in popular magazines in the 1940s and 1950s. There was rapid growth of the sunscreen industry as well, although product efficacy remained highly variable. In the 1950s, interest developed in the use of 8-methoxypsoralen ("the suntan pill") and dihyroxyacetone ("suntan in a bottle"). In spite of the known risks of UV exposure and attempts by physicians and other health professionals to educate the public and modify behavior, suntanning has remained tenaciously popular. Today, excessive UV light exposure is recognized as the major cause of the approximately 1.3 million cases of skin cancer in the United States each year.

Biological UV dosimeters in quality control of tanning tubes

Although according to the International Radiological Protection Association-International Non-Ionizing Radiation Committee recommendation (1991) the use of sunbeds for cosmetic purposes is not recommended, tanning devices are used widely. Ten different types of commercially available sunbed tubes have been studied using a uracil biological UV dosimeter, and three of them were analyzed in detail. Dimerization effectiveness of the tubes was measured directly, whereas efficiency of erythema induction was calculated weighting the emission spectra by the Commission Internationale de l'Eclairage erythema action spectrum. The data obtained demonstrate that quality control of sunbed tubes has to include not only the determination of the UV doses administered but also the assessment of the health risk due to the UVB and UVA components of the lamp. A method of quality control using the uracil biological dosimeter was elaborated, and the estimation of the "acceptable" exposure time was checked/controlled on 15 volunteers by assessing individually the erythema induction threshold. A correct classification of the sunbed tubes is proposed by characterizing the erythema induction versus DNA-damaging effectiveness of tubes.

Examination of the efficacy of an appearance-focused intervention to reduce UV exposure

This study designed and implemented an appearance-based skin cancer prevention intervention in college-aged females. One hundred and forty-seven respondents were randomly assigned to treatment or control groups. Treatment respondents received a short workbook describing the appearance damaging effects of indoor tanning. At short-term follow-up (2 weeks later) treatment respondents had significantly more negative attitudes toward indoor tanning, and reported fewer intentions to indoor tan. At 2-month follow-up, treatment respondents reported indoor tanning one-half as much as control respondents in the previous 2 months. This appearance-based intervention was able to produce clinically significant changes in indoor tanning use tendencies that could have a beneficial effect on the future development of skin cancer.

Tanning salons in southwest Poland: a survey of safety standards and professional knowledge of the staff

BACKGROUND

Nowadays, sunbeds are very popular worldwide; however--in the majority of countries, including Poland--there are no general guidelines and/or regulations for sunbed usage.

PURPOSE

The aim of the study was to evaluate tanning salons in southwest Poland, paying special attention to safety regulations and basic professional knowledge of the staff members of these units. The hypothesis was put that tanning salons offer better skin and eye protection if their employees are more educated.

METHODS

Fifty-five sunbed units were visited by the investigators, acting as potential clients. Information was obtained from the staff members in response to previously designed questionnaire.

RESULTS

Employees of 41.8% of sunbed units had adequate knowledge of radiation used in their establishments. Goggles were provided in 72.7%, sunglasses in additional 25.5% of salons. Lotions with sunscreens were available in 41.8% of units. Brief medical history of the client was taken in 20% of units. No dermatological examination was performed. Tanning salons, where employed staff were well-orientated in ultraviolet radiation emitted in their units, significantly more frequently recommended usage of goggles and sunscreens (P = 0.0037 and P = 0.0033, respectively). Moreover, in these establishments sunscreens were more commonly available (P = 0.0029).

CONCLUSIONS

The knowledge of staff members of tanning salons is poor and the eye and skin protection is not enough. The results point out the importance of the knowledge of the staff members in providing skin and eye protection.

[Population exposure to and protection from artificial ultraviolet radiation]

<zakljucak> Uglavnom se samo vestacki izvori UV zracenja namenjeni kozmetickom tamnjenju mogu smatrati znacajnim sa aspekta mogucnosti ozracivanja pojedinaca iz stanovnistva. Komercijalni izvori UV zracenja za vestacko tamnjenje i oni za kucnu upotrebu su ozbiljan zdravstveni problem jer njihova upotreba moze da poveca rizik od pojave malignih oboljenja koze, a i da dovede do drugog ostecenja zdravlja. Upozorenja strucnjaka o mogucim stetnim efektima vestackog tamnjenja nisu do sada znacajno smanjili broj korisnika izvora za kozmeticko tamnjenje, a najveci broj lica koja se podvrgavaju zracenju su mlade osobe. Dalje preventivne mere treba da budu usmerene ka boljem informisanju javnosti o opasnosti izlaganja i ka ukidanju navike izlaganja vestackim izvorima UV zracenja radi dobijanja tamnog tena.

Indoor tanning facility density in eighty U.S. cities

The purpose of this study was to examine the number of tanning facilities in select U.S. cities. The twenty most populated cities from each of 4 U.S. regions were selected for the sample. For each city, data on the number of tanning facilities, climate, and general demographic profile were collected. Data for state tanning facility legislation also were collected. A tanning facility density variable was created by dividing the city's number of facilities by its population size. The 80 cities had an average of 50 facilities each. Results of linear regression analysis indicated that higher density was significantly associated with colder climate, lower median income, and higher proportion of Whites. These data indicate that indoor tanning facilities are prevalent in the environments of U.S. urban-dwellers. Cities having the higher density profile may be logical targets for interventions promoting less or safer use of these facilities.

Impact of UVA exposure on psychological parameters and circulating serotonin and melatonin

BACKGROUND

People tend to feel better after exposure to ultraviolet (UV) radiation. This study was performed to investigate the impact of UVA exposure on psychological and neuroendocrine parameters.

METHODS

Fifty-three volunteers were separated into 42 individuals who had UVA exposure and 11 individuals who had no UVA exposure. The UVA-exposed volunteers had irradiation sessions six times in a three-week period. All volunteers completed two questionnaires at baseline (T1) and at the end of the study (T3). For the determination of serotonin and melatonin serum levels of all volunteers blood samples were collected at baseline (T1), after the first UVA exposure (T2), and at the end of the study after the sixth exposure (T3).

RESULTS

UVA-exposed volunteers felt significantly more balanced, less nervous, more strengthened, and more satisfied with their appearance at T3. By contrast, the controls did not show significant changes of psychological parameters. In comparison to T1 and T3, serum serotonin was significantly higher and the serum melatonin was significantly lower for the volunteers exposed to UVA at T2. Both, for exposed and non-exposed volunteers serotonin and melatonin levels did not significantly differ at T1 and T3.

CONCLUSIONS

It remains obscure, whether the exposure to UVA or other components of the treatment were responsible for the psychological benefits observed. The changes of circulating neuroendocrine mediators found after UVA exposure at T2 may be due to an UVA-induced effect via a cutaneous pathway. Nevertheless, the positive psychological effects observed in our study cannot be attributed to circulating serotonin or melatonin.

Contrasting effects of an ultraviolet B and an ultraviolet A tanning lamp on interleukin-6, tumour necrosis factor-alpha and intercellular adhesion molecule-1 expression

BACKGROUND

Recent studies have demonstrated that a tanning lamp emitting predominantly ultraviolet (UV) A induces significant yields of the type of potentially mutagenic DNA damage that are associated with the onset of skin cancer (i.e. cyclobutane pyrimidine dimers). UV-induced immunosuppression is also an important event leading to skin cancer.

OBJECTIVES

To the modulation of key immunological molecules following exposure to a broad-spectrum UVB lamp and a predominantly UVA-emitting tanning lamp using model in vitro systems.

METHODS

We compared secretion and mRNA expression of interleukin (IL)-6 and tumour necrosis factor (TNF)-alpha in normal human epidermal keratinocytes, and interferon (IFN)-gamma-induced intracellular adhesion molecule (ICAM)-1 in normal human fibroblasts irradiated in vitro with a broad-spectrum UVB lamp or with a Philips 'Performance' tanning lamp.

RESULTS

With broad-spectrum UVB irradiation, upregulation of IL-6 and TNF-alpha mRNA was detected 6 h after irradiation, and a dose-dependent increase of cytokines in the supernatants of irradiated cells was found 24 h after irradiation. In contrast, there was no cytokine secretion and little evidence for mRNA upregulation following exposure to a tanning lamp. When cells were exposed first to broad-spectrum UVB, then the tanning lamp, UVB-induced cytokine secretion was inhibited, although mRNA levels were upregulated to a level close to that observed with UVB alone. By using a Schott WG 320 nm filter to attenuate the level of UVB relative to UVA emitted by the tanning lamp, the inhibition of cytokine secretion was shown to be associated with UVA exposure. Both UV sources inhibited IFN-gamma-induced ICAM-1 mRNA expression in a dose-dependent fashion. By using a Schott WG 335 nm filter, inhibition of ICAM-1 mRNA expression by the tanning lamp was shown to be associated with UVB exposure.

CONCLUSIONS

These results suggest that UV sources emitting different levels of UVA and UVB have differential effects on the modulation of different immunoregulatory molecules, and indicate that there are potential interactions between these wavelengths.

The value of tan lines: vulvar melanoma and ultraviolet rays

Recreational sun exposure of the general population has increased. There is less clothing on the beaches, increased accessibility to tropical beaches, and increased use of artificial suntanning equipment. The vulva, traditionally, has been protected from sun exposure. In this age of nude sunbathing, particularly within the confines of a tanning bed, it is interesting to ponder whether such exposure would affect the incidence of melanoma of the vulva.

Ultraviolet A and melanoma: a review

The incidence and mortality rates of melanoma have risen for many decades in the United States. Increased exposure to ultraviolet (UV) radiation is generally considered to be responsible. Sunburns, a measure of excess sun exposure, have been identified as a risk factor for the development of melanoma. Because sunburns are primarily due to UVB (280-320 nm) radiation, UVB has been implicated as a potential contributing factor to the pathogenesis of melanoma. The adverse role of UVA (320-400 nm) in this regard is less well studied, and currently there is a great deal of controversy regarding the relationship between UVA exposure and the development of melanoma. This article reviews evidence in the English-language literature that surrounds the controversy concerning a possible role for UVA in the origin of melanoma. Our search found that UVA causes DNA damage via photosensitized reactions that result in the production of oxygen radical species. UVA can induce mutations in various cultured cell lines. Furthermore, in two animal models, the hybrid Xiphophorus fish and the opossum (Mondelphis domestica), melanomas and melanoma precursors can be induced with UVA. UVA radiation has been reported to produce immunosuppression in laboratory animals and in humans. Some epidemiologic studies have reported an increase in melanomas in users of sunbeds and sunscreens and in patients exposed to psoralen and UVA (PUVA) therapy. There is basic scientific evidence of the harmful effects of UVA on DNA, cells and animals. Collectively, these data suggest a potential role for UVA in the pathogenesis of melanoma. To date evidence from epidemiologic studies and clinical observations are inconclusive but seem to be consistent with this hypothesis. Additional research on the possible role of UVA in the pathogenesis of melanoma is required.

Tanning salon exposure and molecular alterations

BACKGROUND

Human studies of the short-term cellular effects of tanning salon exposures are lacking. Findings of such studies may prove extremely helpful in educating consumers considering or currently attending tanning salons.

OBJECTIVE

Our purpose was to determine whether tanning salon exposure causes DNA alterations and p53 protein expression in epidermal keratinocytes and/or circulating peripheral lymphocytes.

METHODS

Eleven subjects received 10 full-body tanning salon exposures over a 2-week period. UV-induced DNA cyclobutane pyrimidine dimers and p53 protein expression were examined, comparing pretreatment peripheral blood lymphocytes and epidermal biopsy specimens with analogous specimens obtained after the 10 tanning salon exposures.

RESULTS

Cyclobutane pyrimidine dimers in DNA and p53 protein expression were detected in epidermal keratinocytes, but were absent in lymphocytes.

CONCLUSION

Similar to outdoor sun exposure, short-term recreational tanning salon exposure causes molecular alterations believed essential in the development of skin cancer.

Compliance with federal and state legislation by indoor tanning facilities in San Diego

BACKGROUND

The prevalence rates of both skin cancers and indoor tanning among the US population are high and have increased substantially in recent years. Low compliance by indoor tanning facilities with safety regulations may place consumers at greater risk of skin and ocular damage.

OBJECTIVE

This study quantified the level of compliance by indoor tanning facilities with selected federal and state regulations and recommendations.

METHODS

Tanning facilities (N = 54) in San Diego County, California, were visited by a confederate posing as a prospective customer. Compliance with 13 regulations/recommendations were assessed by either direct query or observation of the presence/absence of signs and warning labels. Operators' responses to 5 risk-based questions also were noted.

RESULTS

No facility complied with all 13 regulations/recommendations. Compliance with 3 protective eyewear regulations was high (89%-100%). In contrast, compliance with maximum tanning frequency recommendations (approximately 6%) and parental consent regulations (approximately 43%) was disturbingly low.

CONCLUSION

The investigators recommend instituting mandatory, comprehensive training for operators, as well as systematic compliance monitoring with enforcement of penalties for noncompliance.

Attitudes, beliefs and behaviour regarding the use of sunbeds amongst healthcare workers in Bradford

Although cosmetic tanning and unprotected solar exposure are common, little is known about general attitudes, beliefs and behaviour regarding the use of sunbeds. We sought to determine the frequency of sunbeds use in a select sample and to assess the knowledge and beliefs regarding this behaviour. A self-administered anonymous questionnaire was distributed to a sample of 648 employees work for Bradford Hospitals NHS Trust. The questionnaire explored demographic information (including hair and skin type, family history with skin cancer), frequency of sunbeds use, knowledge about the risks of UV exposure and motivations for practising this behaviour. Four hundred and eighteen women and 52 men completed the questionnaire, making a response rate of 73%. Nearly half of respondents (207; 44%) reported using sunbeds to some extent; of those 12% reported frequent use. Appearance ('to look better') was the most popular reason given by respondents for using sunbeds, followed by 'feel healthy'. Frequency of using sunbeds was found to be negatively correlated with the age of respondents and the existence of family experience with skin cancer, and strongly associated with the opinion that it is safer to use a sunbed than subathing outdoors, the female sex and smoking. It is clear from this study that the psychological factors that influence sunbeds use are complex and that so far public education campaigns have had little impact on it. This study highlights some of these psychological factors.

The effect of suntan parlor exposure on delayed and contact hypersensitivity

Cutaneous and systemic immune function are believed to play an important role in cutaneous carcinogenesis. We therefore sought to determine whether the suntan parlor radiation sources commonly used in the United States cause measurable qualitative suppression of immune function and quantitative alterations in circulating T cell subpopulations. Subjects (n = 22) were recruited and randomly assigned to receive suntan parlor exposures (10 full-body UV exposures over a 2 week period, shielding only the right flexural arm) or no exposure. Baseline circulating T lymphocyte subpopulations (T helper lymphocyte, CD4; T suppressor/cytotoxic lymphocyte, CD8) were measured. Two weeks later (upon completion of UV exposures for those in this group), circulating T cell subpopulations were measured and dinitrochlorobenzene (DNCB) sensitization (in the UV group, on the UV-exposed buttock) was performed. Subsequent DNCB elicitation was performed in a bilateral fashion (in the UV group, on the right UV-shielded and the left UV-exposed upper arm). We found that subjects in the UV group demonstrated localized suppression of contact hypersensitivity sensitization and elicitation and also an increase in circulating CD8 cells when compared to the control group (P < or = 0.05). We conclude that suntan parlor exposures, as typically received in this country, suppress contact hypersensitivity and increase the circulating T suppressor/cytotoxic cell number quantity.

Sun-induced skin changes

Chronic sun exposure is responsible for changes in skin texture, pigmentation, vascularity, maturation, and production of neoplasms. A 78% decrease in the lifetime incidence of basal and squamous cell carcinoma has been reported with regular use of SPF 15 sunscreen for the first 18 years of life. Actinic keratoses, sun-induced premalignant lesions of the skin, can be eliminated by mechanical and medication therapies. 5-fluorouracil therapy can be effective treatment for widespread actinic damage.

The health impact of solar radiation and prevention strategies: Report of the Environment Council, American Academy of Dermatology

It is well recognized that exposure to solar radiation is a major risk factor for the development of skin cancer, photoaged skin, and immune system alterations. However, major questions remain regarding the specific wavelengths and type of exposure that incur risk. The purpose of this article is to critically examine, on the basis of current knowledge, the impact of stratospheric ozone depletions, tanning bed skin cancer risk, the safety of sunscreens as an important element of our solar protection strategies, the wavelengths of solar radiation responsible for melanoma, and the incidence of melanoma. Recommendations are made on prevention strategies and public health messages.

Sunbed use in Buenos Aires, Argentina

The objectives were to survey tanning salons in a defined geographic area of Buenos Aires city and to assess the information offered to consumers regarding chronic exposure to ultraviolet radiation, types of radiation used, and safety measures employed. A prospective study using a standardized interview with limited multiple choice responses for data collection was conducted. Results of the interview survey were that 35% of the establishments (tanning salons) said they used UVA exclusively, 6% UVB, and 25% both; 35% did not know the type of radiation to which their clients were exposed. Sunbeds were promoted as healthy in 56% of the tanning salons, whereas potential risks were mentioned in only 15%. One to 3 sessions on the same day were allowed by 84%, while 40% allowed customers to choose the number of weekly sessions. The use of goggles was optional in 65% of the establishments and 21% did not even provide goggles. Use of sunscreens was not compulsory, and none of the salons had associated physicians. Previous history of skin cancer, sunburn or potential photosensitive drug intake were never recorded, and the age of access was not restricted in 71% of the establishments. In Argentina there are no guidelines to regulate the operation of tanning salon establishments or the equipment they use, and there are no specific measures taken to prevent skin and ocular pathologies. Ways to reduce the risks of ocular and skin pathologies from artificial tanning in Argentina are urgently needed.

The 0.8% ultraviolet B content of an ultraviolet A sunlamp induces 75% of cyclobutane pyrimidine dimers in human keratinocytes in vitro

Tanning lamps, emitting predominantly ultraviolet (UV) A, are used widely throughout the U.K. and other countries, but little is known about the long-term risks associated with their use, especially with respect to skin cancer. We have exposed normal human epidermal keratinocytes to a commercial tanning lamp and used the comet assay in association with DNA repair enzymes T4 endonuclease V and endonuclease III to investigate the relative yields of directly formed cyclobutane pyrimidine dimers (CPDs) and indirectly formed types of oxidative DNA damage. To put the risk of using tanning lamps into perspective, the sunbed used in this study (five Philips Performance 80W-R UVA tubes at a distance of 35 cm) was found to be approximately 0.7 times as potent at inducing CPDs as U.K. natural sunlight around noon on a fine summer day. This compares with a relative risk for CPD induction and erythema of 0.8 and 0.7 times, respectively, calculated from the relevant action spectra of tanning lamps and British noontime sunlight. To determine the relative contribution of UVB and UVA to the induction of CPDs and oxidative DNA damage, we modified the spectral output of the tanning lamps with a series of Schott WG UVB filters. The induction of CPDs was more dependent on the UVB component of the sunbed than oxidative types of damage. Schott WG UVB filters with 50% transmission at 305 nm reduced the yield of T4 endonuclease V sites by 42% while there was only a 17% decrease in the yield of endonuclease III sites. CPD induction was not completely abolished after irradiation through WG335 and WG345 nm filters despite there being no detectable UVB. From these data, it was estimated that, although the tanning lamps emitted only 0.8% of their total output in the UVB range, these wavelengths were responsible for the induction of over 75% of CPDs and 50% of the oxidative damage to DNA.