1. The Darker Side of Indoor Tanning Author: Lauren Alderdice Advisor: Professor VanDyke

2. History of Indoor Tanning • 1906: Medical company in Germany made the worlds 1st indoor UV tanning bed used to treat ricketts • 1st generation of indoor tanning beds were principally UVB emitting; plagued by many safety problems • 1970’s: Development of high intensity UVA light sources for medical purposes; was quickly followed by their use in commercial tanning parlors

3. Indoor Tanning Statistics • 30 Million Americans visit indoor tanning salons each year • 70% are Caucasian girls and women between the ages of 16 and 49 • 2005 AAD survey: 92% of respondents understood that getting a tan from the sun is dangerous; Yet, 65% said they think they look better when they are tan.

4. UV Sources in Tanning Beds • UVA: 95%, aging of the skin with recent studies proving cancer and genetic damage. • UVB: 5%, sunburns and skin cancer

5. Reasons for tanning • Recurrent themes :to look good ,relaxation, and to prepare for a special event. (Murray and Turner’s qualitative study) • Prevacation Tan- SPF 3 • Zeller et al. :more difficult to quit tanning at younger ages and higher frequency of use due to the mood-enhancing or relaxing effects. • Feldmen, et al. study :artificial UVR is a reinforcing stimulus in frequent indoor tanners.

6. Adverse Effects of Sunbeds • Sunburn: most apparent acute adverse effect • Determinants: Thickness of skin, skin pigmentation based on hereditary skin type & exposure time • CDC :700 visits were made to ED in a single year due to tanning bed burns • AAD reports in Italy: 25% of sunbed users experience sunburns in devices, but only 60% suspend sessions after burning. • Blistering sunburns (even only a few) 1st 18 yrs of life significantly increase the risk for MM

7. Other Immediate Effects • Ocular disorders: corneal burns, cataracts, & permanent eye damage • CDC : 152 pts had been treated for eye injuries in a 12 month period related to tanning devices • Phototoxic/ Photoallergic Rxns include but are not limited to: NSAIDS, Diuretics, ABX, TCA’s

8. Chronic Adverse Effects • Photoaging • Common in middle-aged, and elderly whites • Coarse, roughened, deeply wrinkled skin, reductions in elasticity and recoil

9. Indoor Tanning & Skin Cancer • UV exposure : most important environmental factor in development • Most common CA in U.S. • Increasing in prevalence • ACS : “ Exposure to sunlight causes almost all cases of basal and squamous cell skin cancer and is a major cause of skin melanoma”

10. Skin CA Cont. • BCC: 80%; Cumulative sun exposure is main risk factor • SCC: 2nd most common; Excess UV exposure • MM: Most fatal; excessive sun exposure (esp. sunburn) most preventable cause • NCI: Women who use tanning beds>1/mo are 55% more likely to develop MM • IARC: 1st exposure to sunbeds before 35 yoa significantly increases the risk of MM

11. How Indoor Tanning Is Regulated • FDA • FTC • Operators of indoor tanning: state level or not at all

12. Pitfalls of Enforcement • FDA ONLY recommends maximum exposure dosages • Survey of tanning facilities in NC :95% of patrons exceeded recommended limits, with 33% beginning at maximum doses recommended for maintenance tanning • FDA DOES NOT regulate the proportion of UVA and UVB emitted • FDA Center for Devices and Radiological Health has shown that on a per-MED basis: UVA doses of 1.1 to 4.1 times that of the sun are used in regular tanning lamps and doses of 10 to 15 times that of the sun in newly available high-pressure sunlamps.

13. Government Position • Contends with the strong lobbying at federal and state levels by the multibillion-dollar tanning industry. • 2003: FDA developed amendment proposals to develop a safer tanning protocol that have yet to be put in place.

14. Bottom Line • Appearance is driving patrons to the readily accessible artificial UVR devices • http://www.youtube.com/watch?v=b2oyYUhl0UE

15. The Role of PA’s Increase efforts to warn and educate the public and government about the dangers of excessive UV exposure Incorporate patient education on artificial tanning in our daily practices Sports physical for adolescents: 5th Vital Sign Evidence that prevention efforts can be effective over time

16. References • Albert MR, Ostheimer KG. The evolution of current medical and popular attitudes toward ultraviolet light exposure: part 3. J Am Acad Dermatol. 2003 Dec; 49(6):1096-1106. • American Academy of Dermatology (AAD). Skin Cancer. 2005. Available at http://www.aad.org/public/Publications/pamphlets/SkinCancer.htm • American Academy of Dermatology (AAD). 2006 Skin Cancer Fact Sheet. Available at • http://www.aad.org/aad/Newsroom/2005+Skin+Cancer+Fact+Sheet.htm • Amercian Cancer Society. Cancer Facts and Figures 2005. Available at http://www.cancer.org • Centers for Disease Control and Prevention (CDC). Epidemiologic Notes and Reports Injuries Associated with Ultraviolet Tanning Devices – Wisconsin. Morbidity and Mortality Weekly Report. 1989 May;38(19):333-335. • Demko CA, Borawski EA, Debanne SM, Cooper KD, Stange KC. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc. 2003; 157: 854-860. • Feldman SR, Liguori A, Kucenic M, Rapp SR, Fleischer Jr. AB, Lang W, et al. • Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol. 2004; 51(1):45-51. • Ferguson, J. WHO says skin cancer incidence is rising. Journal Watch Dermatology. 2005;4 (4). • Gambichler T, Breukmann F, Boms S, Altmeyer P, Kreuter A. Narrowband UVB • phototherapy in skin conditions beyond psoriasis. J Am Acad Dermatol. 2005; 52(4):660-70. • Gorgos D. Popularity of indoor tanning contributes to increased incidence of skin cancer. Dermatology Nursing. 2006 June; 18(3):281. • Hillhouse JJ, Turrisi R. Examination of the efficacy of an appearance-focused intervention to reduce UV exposure. Journal of Behavioral Medicine August 2002; 25(4): 395-409. • Hornung RL, Magee KH, Lee WJ, Hansen LA, Hsieh Y. Tanning facility use: Are we exceeding Food and Drug Administation limits? J Am Acad Dermatol. October 2003; 49(4): 655-660. • IARC Working Group. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review. Int. J. Cancer. 2006; 120:1116-1122. • Isaacs G, Stainer DS, Sensky TE, Moor S, Thiompson C. Phototherapy and its • mechanisms of action in seasonal affective disorder. J Affective Disorder. 1988; 14:13-19. • Knight JM, Kirincivh AN, Farmer E, Hood AF. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol. October 2002; 138(10):1311-11315. • Lee T, Chen E, Chan C, Paterson J, Janzen H, Blashko C. Seasonal affective disorder. Clinical Psychology: Science and Practice. 1998; 5(3):275-90. • Levine JA, Sorace M, Spencer J, Siegel D. The indoor UV tanning industry: A review of • skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol. • 2005; 53(6):1038-44. • Lim HW, Cyr WH, DeFabo E, Robinson J, Weinstock MA, Beer JZ, et al. Scientific and regulatory issues related to indoor tanning. J Am Acad Dermatol. 2004; 51(5):781-4. • Lim HW, Gilchrest BA, Cooper KD, Bischoff-Ferrari HA, Rigel DS, Cyr WH, et al. Sunlight, tanning booths, and vitamin D. J Am Acad Dermatol. 2005; 52(5):868-76. • MacKie R M. Long-term health risk to the skin of ultraviolet light. Progress in Biophysics and Molecular Biology. 2006; 92:92-96. • Morbidity and Mortality Weekly Report (MMWR). Quickstats: percentage of teens aged 14-17 years who used indoor tanning devices during the preceeding12 months, by sex and age---United States, 2005. October 13, 2006; 55(40):1101. • Murray CD, Turner E. Health, risk and sunbed use: A qualitative study. Health, Risk and Society. March 2004; 6(1): 67-80. • National Cancer Institute (NCI). Artificial Tanning Booths and Cancer. 2004. Available at http://www.cancer.gov • Neale, RE, Davis M, Pandeya N, Whiteman DC, Green AC. Basal cell carcinoma on the trunk is associated with excessive sun exposure. J Am Acad Dermatol. In press, Corrected proof, Available online 13 October 2006. • Palmer RC, Mayer JA, Woodruff SI, Eckhardt L, Sallis JF. Indoor tanning facility density in eighty U.S. cities. J. of Community Health. 2002; 27(3):191-202. • Rhainds M, De Guire L, Claveau J. A population based survey on the use of artificial tanning devices in the Province of Quebec, Canada. J Am Acad Dermatol. 1999 Apr; 40(4): 572-6. • Sinclair, C. Risks and benefits of sun exposure: implications for public health practice based on the Australian experience. Progress in Biophysica and Molecular Biology. 2006;92: 173-178.

17. Questions?