1. 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@uic.edu

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

3. 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

4. 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

5. Emergence of tanning 1930’s & 40’s – 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 1970’s – Development of UVA beds for medicinal purposes Commercialization soon after with formation of the Indoor Tanning Association

6. 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

7. Skin Cancers - Melanomas

8. 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

9. Skin types Fitzpatrick’s classification – 1977 SED = sub erythemal dose

10. 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

11. 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

12. 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

13. Indoor Tanning Industry Significant advertising & promotion to students Formed a Political Action Committee (PAC) to prevent ban on under-18 tanning

14. 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

15. Indoor Tanning Source: www.cartoonstock.com

16. Tanning Salon Operators Source: www.cartoonstock.com

17. 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

18. Regulation & Legislation FTC – prohibits deceptive advertising Individual states governance

19. 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

20. Discussion According to Sharon A. Miller at the FDA’s 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

21. 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

22. 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

23. 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

24. 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