AGENDA ITEM SC
April 12, 2016
Action
MEMORANDUM
April 8, 2016
TO:
FROM:
SUBJECT:
County Council
Amanda Mihill, Legislative
Attome~~
Action: Bill 5-16, Tanning Facilities - Amendments
Health and Human Services Committee recommendation (3-0): enact Bill 5-16 with an
amendment to modify the definition of"tanning facilities" to make
it
consistent with state law and
other technical amendments. The Committee recommended that the Council adopt a Board of
Health regulation that would mirror Bill 5-16.
Bill 5-16, Tanning Facilities - Amendments, sponsored by Lead Sponsor Councilmember Hucker,
and Co-Sponsors Council President Nancy Floreen, Councilmernbers Leventhal, Ka1z, Navarro, and
Rice, Council Vice-President Berliner, and Councilmembers Riemer and Elrich was introduced on
March 1, 2016. A public hearing was held on March 22 at which several speakers, including Dr.
Tillman on behalf of the County Executive, supported Bill 5-16. A Health and Human Services
Committee worksession was held on April 4.
Bill 5-16 would prohibit minors from using indoor tanning devices; require tanning facilities and
customers to adhere to certain duties; and require tanning facilities to provide certain warning
statements and post certain signs.
Background
Health concerns associated with tanning devices
According to the Centers for Disease Control
and Prevention (CDC), there are several dangers associated with indoor tanning. These include
increased risk of skin cancer, premature skin aging, and eye diseases (if eye protection is not used).
Although these risks can affect people of all ages, the CDC notes that indoor tanning is particularly
dangerous for young users and states that people who begin using tanning devices during
adolescence or early adulthood have a higher risk of getting melanoma, which is the deadliest type
of skin cancer. (See the Surgeon General's call to Action to Prevent Skin Cancer on ©15-20 and
the CDC fact sheet on ©21-23. See also an "Evaluation of Indoor Tanning Health Claims"
prepared for the New York State Office of the Attorney General on ©24-61.)
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Federal law
Federal law regulates tanning devices as "sunlamp products" and Bill 5-16 is
consistent with existing federal regulations. Council staff notes, that the Food and Drug
Administration recently proposed two new relevant rules. One regulation requires sunlamp
manufactures and tanning facilities to take additional safety measures, some of which are similar
to Bill 5-16. The second regulation would prohibit minors from using sunlamp products. See ©62-
63 for an FDA News Release that summarizes these two proposed rules. The comment period for
these proposed rules closed on March 21.
It
is unclear when (or if) the FDA will issue a final rule
or what that final rule may require or prohibit.
State law
Maryland does not comprehensively regulate the use of tanning facilities or tanning
devices. Section 20-106 of the Health-General Article of the Maryland Code prohibits minors from
using tanning devices unless the minor's parent or legal guardian provides written consent (©80-
82).
Action in other jurisdictions
According to the National Conference of State Legislatures, 12 states
and the District of Columbia ban the use of tanning beds for minors. Many other states regulate
the use of tanning devices by minors. See map on ©64. Since 2009, Howard County, Maryland
prohibits minors from using tanning devices unless they have a written prescription from a
physician.
Public Comments Received
At the public hearing, several individuals supported Bill 5-16. The Council has also received
correspondence from residents supporting Bill 5-16. Select correspondence and testimony is on
©65-78.
The Council also received correspondence from Bruce Bereano on behalf of the Maryland Indoor
Tanning Association opposing Bill 5-16 and arguing that Bill 5-16 is preempted by State law
(©79).
Issues/Committee Recommendation
Preemption
As noted above, Mr. Bereano argued that the County is preempted from banning
minors from using tanning devices. House Bill 1358, which added §20-106 to the Health-General
Article of the Maryland Code, included an uncodified provision that states that the Act "may not
be construed to preempt a county or municipal government from enacting and enforcing more
stringent measures to regulate the use of tanning devices by minors."
Mr.
Bereano argued that this
language expressly permits minors to use a tanning device if their parent provides parental consent.
Council attorneys and the County Attorney disagree with
Mr.
Bereano's analysis. We do not
believe that Bill 5-16 is preempted by State law. The purpose of the state law is to protect minors
from the harmful effects of tanning devices. Because Bill 5-16 furthers this purpose, it does not
conflict with the State law and is therefore not preempted. The case law cited in the County
Attorney memorandum on ©88-90 supports this conclusion.
2
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County Attorney amendments
The County Attorney's Office proposed a number of technical
amendments, of which the Committee recommended approval. Those amendments are included in
the attached Committee bill.
In
addition, the Committee supported the County Attorney's Office
recommendation that the County retain the existing definition of "tanning device" which mirrors
the state definition. The existing definition is broader and easier to understand. See ©2, lines 12-
21:
Other Committee comments
The Committee
was
also concerned regarding outreach to the tanning
facilities in the County. The Committee asked the Department of Health and Human Services to
reach out to impacted facilities to ensure they are aware of the changes required by Bill 5-16.
In
addition, the Committee recommended that the Council adopt a Board of Health Regulation that
mirrors Bill 5-16 to ensure that tanning facilities within municipalities are subject to the same
requirements as other tanning facilities throughout the County. That Board of Health Regulation
is scheduled to be introduced on April 12.
This packet contains:
Bill 5-16
Circle#
1
Legislative Request Report
Sponsor memorandum
The Surgeon General's call to Action to Prevent Skin Cancer
CDC Fact Sheet, "Indoor Tanning is Not Safe"
Evaluation of Indoor Tanning Health Claims
FDA
News Release
National Conference of State Legislatures Map
Select Correspondence
County Executive
Senator Raskin
Delegate Kirill Reznik
American Academy of Dermatology Association
American Cancer Society, Cancer Action Network
Maryland Save Your Skin Coalition
MedChi
LanyGreene
Bruce Bereano
State law
Fiscal and Economic Impact statement
County Attorney memorandum
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Bill No.
5-16
Concerning: Tanning
Facilities
Amendments
Revised: 4/6/2016
Draft No.
-1.__
Introduced:
March 1 2016
Expires:
September 1. 2017
Enacted: - - - - - - - - - -
Executive: - - - - - - - - -
Effective: - - - - - - - - - -
Sunset Date: _.N....,.o.._n=e_ _ _ _ _ __
Ch. _ _ , Laws of Mont. Co. _ _ __
COUNTY COUNCIL
FOR MONTGOMERY COUNTY, MARYLAND
Lead Sponsor: Councilmember Hucker
Co-Sponsors: Council President Nancy
Floree~
Councilmembers Leventhal, Katz, Navarro, and
Rice, Council Vice-President Berliner, and Councilmembers Riemer and Elrich
AN ACT
to:
(1)
(2)
(3)
prohibit minors from using indoor tanning devices;
require tanning facilities and customers to adhere to certain duties;
require tanning facilities to provide certain warning statements and post certain
signs; and
generally amend the law regarding tanning facilities.
(4)
By amending and renumbering
Montgomery County Code
Chapter 5 lA, Tanning Facilities
Sections 51A-1, 51A-2, 51A-3, 51A-4, 51A-5, 51A-6, 51A-7, 51A-8, 51A-9, 51A-10,
51A-11, 51A-12, 51A-13, 51A-14, and 51A-15
Boldface
Underlining
[Single boldface brackets]
Double underlining
[[Double boldface brackets]]
* * *
Heading or defined term.
Added to existing law by original bill.
Deletedfrom existing law by original bill.
Added by amendment.
Deletedfrom existing law or the bill by amendment.
Existing law unqffected by bill.
The County Council for Montgomery County, Maryland approves the following Act:
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BILL No. 5-16
1
Sec. 1. Chapter 51A
is
amended by amending and renumbering Sections
51A-1, 51A-2, 51A-3, 51A-4, 51A-5, 51A-6, 51A-7, 51A-8, 51A-9, 51A-10,
51A-ll, 51A-12, 51A-13, 51A-14, and 51A-15:
51A-1. Definitions.
In this Chapter the following words have the meanings indicated:
[(1 )]
Department
means the Department of Health and Human Services.
[(2)]
Director
means the Director of the Department of Health and Human
Services or the Director's designee.
[(3)]
Tanning facility
means any place where a tanning device is used [for a
fee, membership dues, or any other compensation] regardless of
whether~
fee
is [[charge]] charged for access to the tanning device.
[(
4)]
Tanning device[:
2
3
4
5
6
7
8
9
10
11
12
13
14
15
a.
Means any equipment that emits radiation used for tanning of the
skin, such as a sunlamp, tanning booth, or tanning bed; and
b.
Includes any accompanying equipment, such as protective
eyewear, timers, and handrails.) means any equipment that emits.
[[electromagnetic]] radiation [[having wavelengths in the air
between 200 and 400 nanometers and that is]] used for tanning of
[[human]] the skin. such as a sunlamp. tanning bootli. or tanning
bed.
Tanning device
includes any accompanying equipment,
including protective eyewear, timers, and handrails.
16
17
18
19
20
21
22
23
24
[51A-2. Scope.]
[This chapter does not apply to a licensed health care professional who uses a
tanning device.]
25
[51A-4] 51A-2. License required.
{j)
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BILL NO. 5-16
26
(a)
[It
is unlawful for any person to] A person must not operate a tanning
27
facility without a valid license issued by the [department] Department
under this [chapter] Chapter.
(b)
A license authorizes a person to operate a tanning facility only at the
location identified in the license.
(
c)
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A license issued under this [chapter] Chapter is not transferable.
However, a new owner may continue to operate a tanning facility under
the terms of the previous license if:
(1)
[The] the new owner has applied for a license under this [chapter]
Chapter; and
(2)
[The] the license of the previous owner has not expired or been
suspended or revoked.
35
36
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38
.
[51A-5] 51A-3. Application for license.
39
(a)
In general.
A person who wants to operate a tanning facility must:
(
1)
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[Submit] submit an application to the [department] Department
on the form that the [department] Department requires; and
(2)
[Pay]
~
to the [department] Department a license fee
in
the
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47
amount that the [county executive] County Executive determines
by regulation adopted under [method] Method (3).
(b)
Contents ofform.
The application must include:
(1)
(2)
[The] the name and address of the applicant;
[The] the location and telephone number of the tanning facility
for which the application is made;
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(3)
[The] the name, description and year of manufacture of each
tanning device used by the tanning facility; and
(4)
[Any] any other information that the [department] Department
requires.
52
0
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BILL No. 5-16
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(c)
New equipment.
A person who operates a tanning facility must notify
the [department] Department of the name, description, and year of
manufacture of any new equipment it uses within
[thirty
(30)] 30 days
after installing the new equipment for use.
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[51A-6] 51A-4. Issuance of license; inspection.
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(a)
Issuance.
The [department] Department must issue a license to any
person who:
(1)
[Submits] submits an application under [section 5 lA-5] Section
[[51A-4]] 51A-3;
(2)
[Pays]
Pm
the license fee required under [section 5 lA-5]
Section [[51A-4]] 51A-3; and
(3)
[Meets] meets all other requirements of this [chapter] Chapter.
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(b)
Inspection.
Before issuing a license [under this chapter], the
[department] Department must inspect a tanning facility to determine
whether it meets the requirements of this [chapter] Chapter.
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[51A-7. License.]
[(a)]
ill
Contents gflicense.
A license must include:
(1)
(2)
[The] the name of the licensee;
[The] the location of the tanning facility for which the license is
issued;
(3)
(4)
[The] the date that the license expires; and
[Any] any other information that the [department] Department
reqmres.
[(b)]@
Term
gf
license.
A license is valid for [one
(I)]
issuance.
[(c)]
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l
year after its date of
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W
Display.
A licensee must display the license conspicuously in the
tanning facility.
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BILL
No.
5-16
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[51A-8. Renewal] 51A-5. License renewal.
(a)
Application.
A. licensee may renew a license if,
[thirty
(30)] 30 days
before the license expires, the licensee:
(1)
[Submits] submits to the [department] Department a renewal
application on the form that the [department] Department
reqmres;
(2)
[Pays]
mY§
a renewal fee equal to the license fee established
under [section 51A-5] Section [[51A-4]) 51A-3; and
(3)
[Meets] meets all other requirements of this [chapter] Chapter.
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(b)
Extension.
An existing license continues in effect until the [department]
Department acts on the renewal application if:
(1)
(2)
[The] the licensee meets the requirements of subsection (a); and
[The] the existing license has not been suspended or revoked.
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92
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(
c)
Term.
A license is valid for [one (1)]
l
year after its date of renewal.
[SlA-11) 51A-6. Standard for tanning devices.
Any tanning device used by a tanning facility must meet performance
standards based on applicable federal law and regulations for the protection of the
public health as established by the [county executive] County Executive.
[SlA-13) SlA-7. [Use requirements] Duties; prohibition of
~fil;:
minors.
(a)
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Tanningfacility.
A tanning facility must:
(1)
[Have] have a trained attendant on duty whenever the facility is
open for business;
(2)
[a.) (A) [Provide] provide each customer with protective eyewear
that meets the standards for tanning devices established
under this [chapter] Chapter; and
1O1
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103
104
0
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BILL
No. 5-16
105
[b.]
on
[Not allow] prohibit a person [to use] from using a
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tanning device if that person does not use the protective
eyewear.
(3)
[Show] show each customer how to use suitable physical aids,
such as handrails and markings on the floor, to maintain proper
exposure distance as recommended by the manufacturer;
(4)
[Limit] limit each customer to the maximum exposure time as
recommended by the manufacturer;
(5)
ensure that
f!
timing device that is accurate [[with]] within 10% of
any selected timer interval is used and is remotely located so
customers cannot set their own exposure time;
.(fil
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[Control] control the interior temperature of a tanning facility so
that it does not exceed [the temperature that the county executive
determines by regulation under method (3)] 100 degrees
Fahrenheit;
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122
ill
.(fil
ensure that each tanning device is equipped with
fl
mechanism
that allows
f!
customer to
turn
the tanning device off;
prohibit
fl
customer from using
B:
tanning device in the facility
more than once every 24 hours;
123
124
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126
CD
sanitize each tanning device after each use;
QQ}
provide
fl
written warning as required in Section [[51A-9]]
51A-8; and
ill)
maintain records as required in Section [[51A-10]] 51A-9.
127
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131
(b)
Customer.
(1)
Either each time a person uses a tanning facility, or each time a
person executes or renews a contract to use a tanning facility, the
person must sign a written statement that the person:
G)
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BILL NO.
5-16
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[a.] (A) [Has] has read and understood the warnmgs before using
the device; and
[b.]
ill)
[Agrees] agrees to use the protective eyewear that the
tanning facility provides.
(2)
When using a tanning device, a person must use the protective
eyewear that the tanning facility provides.
[(3)
A person under the age of eighteen (18) must be accompanied by
a parent or legal guardian when using a tanning device.]
g}
A person under the age of 18 must not use
~
tanning
device.
[51A-12] 51A-8. Warnings.
(a)
Warning Statement.
A tanning facility must give each customer a
written statement warning that:
(
1)
[The] the customer must use the protective eyewear that the
tanning facility provides to avoid damage to the eyes;
(2)
(3)
[Overexposure] overexposure causes bums;
[Repeated] repeated exposure may cause premature aging of the
skin and skin cancer;
(4)
[Abnormal] abnormal skin sensitivity or burning may be caused
by
certain:
150
151
[a.
[b.
[c.
[d.
[e.
[f.
Foods] (A) foods;
Cosmetics]
ill)
cosmetics;
Tranquilizers]
.cg
tranquilizers;
Diuretics]
ill)
diuretics;
Antibiotics]
.{fil
antibiotics;
High]
(El~
blood pressure medicines; and
Birth]
(ill
birth control pills; and
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153
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156
157
[g.
{j)
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BILL No. 5-16
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(
e)
(5)
Any person taking a prescription or over-the-counter drug should
consult a physician before using a tanning device[.t
@
it is
~
violation of County Code §5 lA-8 for
~
person under the
age of 18 to use
~
tanning device.
(b)
In the warning statement required under subsection (a), a tanning
facility must tell its customers:
(
1)
[How] how much liability insurance it carries for the kinds of
injuries listed in subsection (a); or
(2)
[That] that it does not carry liability insurance for the kinds of
injuries listed in subsection (a).
(c)
Warning Sign.
A tanning facility must post a warning sign in any area
where a tanning device is used. The [county executive] Executive must
determine the content and size of the warning sign by regulation under
[method] Method (3). However,
at~
minimum, the
.filgn
must state that
for~
it is
~
violation of County Code
§5
lA-13
18 to use
~
tanning device.
(
d)
person under the age of
A tanning facility must not claim, or distribute promotional materials
that claim, that using a tanning device is safe or free from risk.
The liability of a facility operator or a manufacturer of a tanning device
is not changed by giving the warning under this [section] Section.
[SlA-14] SlA-9. Injury
report; records.
(a)
Injury report.
(1)
Tanningfacility.
A tanning facility must:
[a.] (A) [Report] report any injury, or any complaint of injury, to
the [department] Department on the form that the
[department] Department requires; and
0
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BILL
No.
5-16
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[b.]
(ID
[Send] send a copy of the injury report to the person who
is injured or complains of an injury.
(2)
Department.
The [department] Department must send to the
[food and drug administration] Food and Drug Administration a
report of all injuries in a tanning facility.
(b)
Records.
A tanning facility must keep a record of each customer's use of
a tanning device. The [county executive] Executive must determine by
regulation a reasonable length of time and the manner that records must
be kept.
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192
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194
[51A-9] 51A-10. Right of entry.
The [department] Department may inspect any tanning facility whenever it is
open to the public for business to determine whether the tanning facility meets the
requirements of this [chapter] Chapter.
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196
197
198
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200
201
202
[SlA-3] 51A-11. Administration; regulations.
The Department [of Health and Human Services is responsible for
administering and enforcing] must administer and enforce this Chapter. The County
Executive must issue regulations for administering this Chapter under [method]
Method (2). These regulations should include standards for hygiene, injury reports,
training of attendants, and the meaning of health care professional.
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208
209
21
o
[51A-10] 51A-12. Enforcement.
(a)
Order to comply.
The [director] Director may order a licensee to comply
with the provisions of this [chapter] Chapter. The [county attorney]
County Attorney may file an action in any competent court to enforce
an order under this [section] Section or to enjoin
any
violation of this
[chapter] Chapter.
(b)
Denial, suspension, revocation.
The [department] Director may deny,
suspend, or revoke a license under this [chapter] Chapter if the
(j)
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BILL NO.
5-16
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[director] Director
finds,
after a hearing for which written notice has
been given, that an applicant or licensee has:
(1)
[Made] made a material false statement on an application for an
initial or renewal license;
(2)
(3)
[Obtained] obtained a license by fraud or deceit;
[Failed] failed to conform to the provisions of this [chapter]
Chapter;
(4)
[Refused] refused lawful entry to any person authorized to
enforce this [chapter] Chapter; or
(5)
[Failed] failed to comply with an order under this [section]
Section.
(
c)
Summary closing.
(1)
The [director] Director may summarily suspend or revoke a
license under this [chapter] Chapter if the [director] Director
finds that the tanning facility presents an immediate threat to the
public health or safety.
(2)
If
the [director] Director summarily suspends or revokes a license
under this [section] Section, the [director] Director must:
[a. ] (A) [Give] give the licensee written notice as soon as
possible; and
[b.]
ill}
[Hold] hold a hearing within [forty-eight (48)] 48 hours
after receiving a written request for a hearing from the
licensee.
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233
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235
236
237
(
d)
Reinstatement.
Any person whose license has been suspended or
revoked under this [section] Section may apply to the [director] Director
for reinstatement of the license. Upon receipt of an application for
reinstatement, the [director] Director must inspect the tanning facility
®
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BILL
No.
5-16
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and must reinstate the license if the tanning facility conforms to the
provisions of this [chapter] Chapter.
(e)
Notice.
Notice to an applicant or licensee under this [section] Section is
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effective if:
( 1)
(2)
(3)
[Served] served personally on the applicant or licensee;
[Mailed] mailed by certified mail to the applicant or licensee; [or]
[Posted] posted on the door of the residence of the applicant or
licensee(,]; or
®
(
f)
posted on the door of the tanning facility.
Appeal.
Any person aggrieved by a denial, suspension, or revocation
under this [section] Section may file an appeal with the Montgomery
County Board of Appeals within [ten (10)] 10 days after receipt of the
denial, suspension, or revocation. An order to comply is not appealable
under this subsection. The filing of an appeal does not stay an action
under this [section] Section unless the action expressly provides for a
stay upon appeal.
[51A-15. Penalty] 51A-13. Penalties.
[A person who does not comply with the provisions of this chapter or the
regulations adopted under this chapter may be punished for a class A violation under
section 1-19] Any violation of this Chapter or any regulation adopted under it is
Class A violation. Each day a violation continues is a separate offense.
~
@
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LEGISLATIVE REQUEST REPORT
Bill 5-16
Tanning Facilities -Amendments
DESCRIPTION:
PROBLEM:
Bill 5-16 would generally update County law related to tanning
facilities and prohibit minors from using tanning facilities.
The current laws related to tanning facilities were originally
established in 1987 and infrequently amended since then. There have
been increased knowledge about the risks of indoor tanning facilities
since that time.
According to the Centers for Disease Control and Prevention, the use
of tanning facilities is particularly dangerous for younger users
because people who begin indoor tanning during adolescence or early
adulthood have a higher risk of getting melanoma, the deadliest form
of skin cancer.
GOALS AND
OBJECTIVES:
COORDINATION:
FISCAL IMPACT:
ECONOMIC
IMPACT:
EVALUATION:
EXPERIENCE
ELSEWHERE:
SOURCE OF
INFORMATION:
APPLICATION
WITHIN
MUNICIPALITIES:
PENALTIES:
To protect public health by updating the general laws related to tanning
facilities and prohibit minors from using tanning facilities.
Department of Health and Human Services
To be requested.
To be requested.
To be requested.
To be researched.
Amanda Mihill, 240-777-7815
Not applicable.
Class A violation.
F:\LAW\BILLS\1605 Tanning Faci!ities\LRR.Docx
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MONTGOMERY COUNTY COUNCIL
ROCKVILLE, MARYLAND
TO: Councilmembers
FROM: Councilmember Tom Rucker
DATE: March 1, 2016
RE: Tanning Safety Bill
Today I am introducing legislation that will provide several key health and safety updates
to existing Montgomery County law on the operation and use of indoor tanning facilities. One of
these updates is to prohibit the use of indoor tanning facilities by minors under the age of 18. I
hope you will consider co-sponsoring.
In
2009 indoor tanning devices such as tanning beds, tanning booths, and sun lamps were
classified by the World Health Organization as Class I human carcinogens (the same category as
cigarettes) on the basis of strong evidence linking indoor tanning to increased risk of skin
cancer. Skin cancer is the most commonly diagnosed cancer in the U.S., with melanoma being
one of the most common types found in adolescents and young adults. Beginning indoor tanning
at a young age increases exposure to harmful ultraviolet radiation and is clearly linked to a
higher lifetime risk of cancer. As a result of the indoor tanning industry marketing heavily to
young women, a 2011 CDC study showed that 20.9% of all U.S. female high school students had
indoor tanned with female 17-year old students at 27.90/o.
Montgomery County's tanning regulations were put into place in the 1980's and have not
been updated since. I worked with the American Cancer Society to craft this bill to update the
existing County law on indoor tanning facilities, taking guidance from the latest scientific
research as well as their model statute regulating indoor tanning facilities. Currently minors in
Montgomery County under the age of 18 are permitted to use indoor tanning devices when
accompanied by a parent or legal guardian. Since indoor tanning has been conclusively shown to
increase the risk of skin cancer, our bill would change this, so that minors under the age of 18
can no longer use indoor tanning facilities under any circumstances. This legislation would also
supplement the existing County law by requiring tanning devices to have an "off' button that the
customer can reach during use, have a remotely located timer so that customers cannot set their
own exposure time, and prohibit use by the same customer more than once every 24 hours. This
bill would not cover spray tanning facilities or products, so for teens who insist on artificial
tanning, that option would still be available.
As of May 2015, 12 states (California, Delaware, Hawaii, Illinois, Louisiana, Minnesota,
Nevada, New Hampshire, Oregon, Texas, Vermont, Washington) and the District of Columbia
had adopted legislation prohibiting the use of indoor tanning facilities by minors. Many
European and Scandinavian countries have laws preventing minors from using indoor tanning
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facilities while Brazil and New South Wales, Australia have passed complete bans on all indoor
tanning.
In
2009, Howard County, Maryland became the first local jurisdiction in the country to
ban indoor tanning by minors, followed by Chicago and many others.
Surely we will hear from our County's indoor tanning facilities operators that this change
will hurt their businesses. However, scientific research points clearly to the conclusion that
indoor tanning devices are dangerous and contribute to higher incidences of skin cancer and that
it is especially hann:ful when initiated at a young age. By law we attempt to shield our children
and teenagers under the age of 18 from the harmful health effects of tobacco and non-tobacco
smoking products, and we should do same here.
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3117/2016
The Surgeon General's Call
to
Action
to
Prevent Skin Cancer
I
SurgeonGeneral.QCN
The Surgeon General's Call to Action to Prevent Skin Cancer
Executive Summary
The
Surgeon General
!f
Call to Action to Prevent Skin Cancer
calls on partners
in
prevention from various sectors across the nation to address skin cancer as a major
public health problem. Federal, state, tribal, local, and territorial governments; members of the business, health care, and education sectors; community, nonprofit, and
faith-based organizations; and individuals and families are all essential partners
in
this effort. The goal of this document is to increase awareness of
skin
cancer and to
call for actions to reduce its risk. The
Call to Action
presents the following five strategic goals to support skin cancer prevention in the United States: increase
opportunities for sun protection
in
outdoor settings; provide individuals with the information they need to make informed, healthy choices about ultraviolet
(UV)
radiation exposure; promote policies that advance the national goal of preventing skin cancer; reduce harms from indoor tanning; and strengthen research, surveillance,
monitoring, and evaluation related to skin cancer prevention.
Skin Cancer as a Major Public Health Problem
Skin cancer is the most commonly diagnosed cancer in the United States, and most cases are preventable.1=.l Skin cancer greatly
~ffects
quality oflife, and it can be
disfiguring or even
deadly.~
Medical treatment for skin cancer creates substantial health care costs for individuals, families, and the nation. The number of
Americans who have had skin cancer at some point in the last three decades is estimated to be higher than the number for all other cancers combined,
1
and skin cancer
incidence rates have continued to increase in recent years.U
Each year in the United States, nearly 5 million people are treated for all skin cancers combined, with an annual cost estimated at $8. I billion.2 Melanoma is
responsible for the most deaths of all skin cancers, with nearly 9,000 people dying from it each year.
.W
It
is also one of the most common types of cancer among U.S.
adolescents and young adults.11 Annually, about $3.3 billion of skin cancer treatment costs are attributable to melanoma.2
Despite efforts to address skin cancer risk factors, such as inadequate sun protection and intentional tanning behaviors, skin cancer rates, including rates of melanoma,
have continued to increase in the United States and worldwide.1.1
2- 16
With adequate support and a unified approach, comprehensive, communitywide efforts to
prevent skin cancer can woFk. Although such success will require a sustained commitment and coordination across diverse partners and sectors, significant reductions
in illness, deaths, and health care costs related to skin cancer can be achieved.
Although genetic factors, such as being fair-skinned or having a family history of skin cancer, contribute to a person's risk,.ll::ll the most common types of skin cancer
are also strongly associated with exposure to UV radiation.J.JB!! As many as 90% of melanomas are estimated to be caused by UV exposure.
2431l
UV exposure is
also the most preventable cause of skin cancer. The
Call to Action
focuses on reducing UV exposure, with an emphasis on addressing excessive, avoidable, or
unnecessary UV exposures (such as prolonged sun exposure without adequate sun protection) and intentional exposure for the purpose of skin tanning (whether
indoors using an artificial UV device or outdoors while sunbathing).
UV radiation is a type of electromagnetic radiation emitted by the sun and from some man-made lights, with wavelengths longer than X-rays but shorter than visible
light.ll.ll UV exposure stimulates melanocytes to produce melanin, often resulting in a tan or sunburn, both of which indicate overexposure and damage to the skin,
skin cells, and DNA within those skin cells.llM This damage can lead to cancer. The degree to which UV exposure increases a person's risk of skin cancer depends on
many factors, such as individual skin type, the amount and types of sun protection used, whether exposure is constant or intermittent, and the age at which the
exposure
occurs.l4J.!!~
By reducing intentional UV exposure and increasing sun protection, many skin cancer cases can be
prevented.l~
'
For most people in the United States, the sun is the most common source of exposure to UV radiation. UV radiation from indoor tanning devices
is
a less common but
more easily avoidable source of UV radiation exposure than from the sun. Indoor tanning devices, such as tanning beds, tanning booths, and sun lamps, expose users to
intense UV radiation as a way to
tan
the
skin for cosmetic reasons. Although reducing UV overexposure from the sun can be challenging for some people, UV
exposure from indoor tanning is completely avoidable.
In 2009, the World Health Organization (WHO) classified indoor tanning devices as Class I human carcinogens on the basis of strong evidence linking indoor tanning
to increased risk of skin cancer.Mi A 2014 meta-analysis estimated that more than 400,000 cases of skin cancer may be related
to
indoor tanning in the United States
each year: 245,000 basal cell carcinomas, 168,000 squamous cell carcinomas, and 6,000 melanomas.il Initiating indoor tanning at younger ages appears to be more
strongly related to lifetime skin cancer risk, possibly because of the accumulation of exposure over time from more years oftanning.il::il
The relationship between outdoor UV exposure, vitamin D, and human health is complex. The amount of outdoor sun exposure needed for meaningful vitamin D
production depends on many factors, including time of day, time of year, latitude, altitude, weather conditions, a person's skin type, amount of skin exposed to the sun,
other individual circumstances, and reflective surfaces, such as snow, water, and sand. Adequate vitamin D can be obtained safely through food and dietary
supplements without the risks associated with overexposure to UV radiation.:46..41 Although all UV exposures can affect skin cancer risk, entirely avoiding UV rays
from the sun is neither realistic nor advisa\lle for most Americans. Spending time outdoors is associated with positive health benefits, such as increased levels of
physical activity and improved mental
health.~
Reducing the Risk of Skin Cancer
Most skin cancers are at least partially caused by UV exposure, so reducing exposure reduces skin cancer risk. However, one out of every three U.S. adults has been@
sunburned in the past year, and most do not take recommended actions to protect themselves from the
sun.~
In addition, indoor tanning rates are high among some
1/6
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3117/2016
The Surgeon General's Call
to
Action
to
Prevent Skin Cancer
I
SurgeonGeneral.gov
groups, such as young, non-Hispanic white females, and skin cancer incidence rates are increasing. These facts show a need to take action to improve sun protection
behaviors and address the harms of indoor tanning.
Individuals can take steps
to
reduce their risk of developing skin cancer. Sun protection helps prevent the harmful effects of sun exposure, including sunburn, skin
cancer, premature skin
aging,
and eye damage. When
used
as part of a comprehensive approach, well-tailored, individual-focused strategies may be effective for
reaching specific
subpopulations.il~
According
to
WHO's International Agency for Research on Cancer, ideal sun protection involves several behaviors, including
wearing tightly woven protective clothing, wearing a hat that provides adequate shade to the whole head, seeking shade whenever possible, avoiding outdoor activities
during periods of peak sunlight (such as midday), and using sunscreen (in conjunction with other sun protection behaviors).ll
There are barriers to using sun protection. Many Americans lack a general knowledge or awareness about the risks associated with sun exposure, or they think they are
at low risk of developing skin cancer or
sunburn.~
Social norms regarding tanned skin as attractive and healthy create barriers to reducing intentional exposure to
UV radiation, whether indoors or outdoors. Intentional tanning, which includes both indoor tanning and seeking a tan outdoors, is strongly associated with a preference
for tanned skin and other appearance-focused
behaviors.~
Women in particular may experience greater social pressure to tan and have tanned skin, which likely
explains the higher rates of indoor tanning observed among women
than
men.~
Sunburns in childhood are a clear risk factor for skin cancers later in life,
and
building healthy habits early when children are more receptive can lead to increased sun
protection into adulthood.!iMi Given the amount of time children spend
in
school settings, much of the skin cancer prevention efforts for children have focused on
sun-safety education in schools and changes to the school environment to promote sun-safe behaviors.
Similar to schools, outdoor work settings are an important setting for efforts
to
prevent overexposure
to
the sun and reduce skin cancer risk. Research
has
shown that
skin cancer prevention interventions designed to reach outdoor workers can be highly effective
at
increasing sun protection behaviors and decreasing sunburns.1.Q The
Guide to Community Preventive Services (The Community Guide') states that sufficient evidence exists to recommend multicomponent, communitywide
interventions,!:t as well as interventions designed for certain settings (specifically, child care centers, primary
and
middle schools, outdoor recreational and tourism
settings, and outdoor occupational settings).1.Q
Intervention strategies that address social and contextual factors have
the
potential for broad public health impact by making the healthy choice the easy or default
choice.11 Policies, legislation, and regulation are examples of such interventions, reaching wide segments of communities while requiring minimal individual effort
compared with interventions directed at individuals.11
Policies that address skin cancer prevention vary across the country. Only a few states, such as California and New York, have passed legislation requiring that schools
allow students to use sun-protective clothing (California) or sunscreen (California and New York) on campus..11.Zl California law also urges employers to identify and
correct workplace hazards connected to UV radiation.H.
A few states have passed legislation to support sun-safety education programs and skin cancer prevention awareness. Laws in Arizona and New York mandate
instruction on skin cancer prevention as part of the health education curriculum in public
schools.~
Kentucky passed a law encouraging skin cancer education in
schools.11 Some states have policies that reach beyond children as the audience for education and awareness. New York mandates sun-safety education for all state
employees that spend more than
5
hours per week outdoors.1.S.
Some states and municipalities in the United States have regulations relating
to
use of indoor tanning devices. Considerable variation exists throughout the country in
the strength and enforcement of indoor tanning restrictions, as well as compliance with these restrictions. In October 2011, California passed the most stringent youth
access law in the country, which took effect on January 1, 2012, and prohibits indoor tanning for anybody younger
than
age 18 years.12 Since then, Vermont, Nevada,
Oregon,£ Texas, Illinois, Washington,£ Minnesota, Louisiana, and Hawaii have also adopted prohibitions on indoor tanning for minors younger than age 18 years.12::ll
Currently, at least 44 states and the District of Columbia have some kind of law or regulation related to indoor tanning, including bans on indoor tanning for minors
under a certain age (ranging from 14 to 18), laws requiring parental accompaniment or parental permission, or regulations that otheIWise reduce banns (such as
requiring eye protection).Z2:::ll Indoor tanning laws, particularly those that include age restrictions, appear to be effective in reducing indoor tanning among female
high school students, who have the highest rates .
.§2
Federal policies, legislation, and regulations can help prevent skin cancer. The U.S. Department of Health and Human Services (HHS) and its agencies play important
roles in skin cancer prevention at the federal level. These agencies include the National Cancer Institute in the National Institutes of Health, the Centers for Disease
Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and the Agency for Healthcare Research and Quality. CDC supports Comprehensive
Cancer Control Programs in states, tribes, and territories, many of which conduct activities related to skin cancer prevention. Federal entities outside HHS also address
skin cancer prevention, including the Federal Trade Commission, the U.S. Environmental Protection Agency, the National Park Service, and the Occupational Safety
and Health Administration.
Sunscreens sold in the United States are governed by FDA as over-the-counter drugs. Regulations identify acceptable active ingredients and dosage strengths, provide
language and format for product labels, and establish standardized test methods for determining a product's sun protection factor (SPF), among other requirements.
Products that satisfy regulatory conditions are considered to be safe, effective,
and
truthfully labeled and may be marketed without premarket review and approval by
FDA. Products that vary from regulatory conditions may be sold only after FDA review and approvaJ.ll Under the FDA regulations, all sunscreen products are labeled
for use to help prevent sunburn, and they must state the product's SPF. Sunscreens that pass a separate test for broad spectrum (UVA and UVB) protection may also be
labeled as "broad spectrum." In addition, broad spectrum sunscreens with SPF levels of 15 or higher may be labeled as reducing the risk of skin cancer and premature
skin aging when used together with other sun protection measures, including limiting time in the sun
and
wearing long-sleeved shirts, pants, bats, and sunglasses.li
FDA also regulates indoor UV tanning devices under separate authorities, both as medical devices and as radiation-emitting electronic products. On May 29, 2014,
FDA reclassified indoor tanning devices to Class II medical devices (moderate to high risk).llM Once the reclassification order is effective, manufacturers will have
to include a warning that people younger than age 18 years should not use these devices, receive premarket notification 510(k:) clearance from FDA for newly
marketed devices, and meet other requirements.2!!
The Surgeon Generals Call to Action to Prevent Skin Cancer
is informed by international efforts to prevent skin cancer. Other countties have taken a variety of
approaches to prevent skin cancer, including community-based, multicomponent interventions, which are recommended by The Community Guide.1ll..il Data from
efforts in Australia provide evidence that sustained funding for a community-level skin cancer prevention initiative can improve health outcomes and result in long-
term
savings in health care costs.22.
Many countties have laws specifically addressing indoor tanning. Brazil and New South Wales, Australia, have passed complete bans on indoor tanning.
93 94
In
addition, as of January 2014, France, Spain, Portugal, Germany, Austria, Belgium, the United Kingdom, Australia, Iceland, Italy, Finland, and NoIWay prohibit indoor
tanning for youth younger than age 18 years.il..2!
@
216
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3117/2016
The
Surgeon
General's
Call to Action
to
Prevent Skin Cancer
I
SurgeonGeneral.gov
Gaps in Research and Surveillance
Important strides have been made in skin cancer prevention in the United States, but they have not been sufficient to curb the rising rates of skin cancer incidence.
Social and behavioral research can help us better understand some issues, such as ongoing high rates of sunbum despite improvements in sun protection and ongoing
high rates of indoor tanning despite evidence that it is a human carcinogen. More infurmation is needed regarding effective message
framing
and effective policies to
promote behavior change. Reliable data are also needed to measure the effect of prevention efforts. Many skin cancer cases are not being captured by current
surveillance systems, and current behavioral surveillance systems may not be adequate to track the effect of state and local initiatives, such as indoor tanning
legislation for minors.
Calls to Action
This section presents five strategic goals to support skin cancer prevention in the United States. Federal, state, tribal, local, and territorial governments; businesses,
employers, and labor representatives; health care systems, insurers, and clinicians; early learning centers, schools, colleges, and universities; community, nonprofit, and
faith-based organizations; and individuals and families are
all
essential partners in
this
effort. Strategies that change the context or environment
to
support healthy
choices generally have greater reach and are more effective at the population level than strategies focused on individual behavior.11 This section also provides
education and communication strategies, which will likely be most effective if used
in
conjunction with changes to the social context and environment. Involving
partners across disciplines, sectors, and institutions
will
be essential to addressing the rising incidence of skin cancers in the United States.
Goal 1: Increase Opportunities for Sun Protection
in
Outdoor Settings
Strategies
Increase shade in outdoor recreational settings.
Support sun-protective behaviors in outdoor settings.
Increase availability of sun protection in educational settings.
Increase availability of sun protection for outdoor worlcers.
Goal 2: Provide Individuals with the Information They Need to Make Informed, Healthy Choices About UV Exposure
Strategies
Develop effective messages and interventions for specific audiences.
Support skin cancer prevention education in schools.
Integrate sun safety into workplace health education and promotion programs.
Partner with health care systems and providers to implement and monitor use of recommended preventive services for provider counseling on skin cancer
prevention.
• Establish partnerships between public and private sectors to disseminate effective messages about skin cancer prevention.
• Enhance ongoing engagement of federal partners to advance our nation's skin cancer prevention efforts.
Goal 3: Promote Policies that Advance the National Goal of Preventing Skin Cancer
Strategies
Support inclusion of sun protection in school policies, construction of school facilities, and school curricula.
Promote electronic reporting of reportable skin cancers and encourage health care systems and providers
to
use such systems.
Incorporate sun safety into workplace policies and safety trainings.
Support shade planning in land use development.
Goal 4: Reduce Harms from Indoor Tanning
Strategies
Monitor indoor tanning attitudes, beliefs,
and
behaviors in the U.S. population, especially among indoor tanners, youth, and parents.
Continue to develop, disseminate, and evaluate tailored messages
to
reduce indoor tanning among populations at high risk.
Support organizational policies that discourage indoor tanning by adolescents and young adults.
Enforce existing indoor tanning laws and consider adopting additional restrictions.
Address the risks of indoor tanning with improved warning labels and updated performance standards.
Goal 5: Strengthen Research, Surveillance, Monitoring, and Evaluation Related to Skin Cancer Prevention
Strategies
Enhance understanding of the burden of skin cancer and its relationship with UV radiation.
Evaluate the effect of interventions and policies on behavioral and health outcomes.
Build on behavioral research and surveillance related to UV exposure.
Quantify the prevalence of tanning in unsupervised locations.
Conclusion
With this
Call to Action,
the U.S. Surgeon General emphasizes the need to act now to solve the major public health problem of skin cancer. To reduce skin cancers in
the population, people must get the information they need to make informed choices about sun protection, policies must support these efforts, youth must be protected
from harms of indoor tanning, and adequate investments need
to
be made in skin cancer research and surveillance.
@
316
Achieving these goals will not be a small task. It will require dedication, ingenuity, skill, and the concerted efforts of many partners in prevention across many different
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3117/2016
The Surgeon General's Call to Action to Prevent Skin Cancer
I
SurgeonGeneral.gov
sectors. Many of these partners are already enthusiastically involved, but greater coordination and support are needed to increase the reach of their efforts. The goals
and strategies outlined in the
Call to Action
are the next steps. We must act with urgency to stop the ever-increasing incidence of skin cancers in the United States.
Footnotes
a The Community Guide is a website that houses the official collection of all Community Preventive Services Task Force findings and the systematic reviews on which
they
are
based.
b Multicomponent, communitywide interventions are defined as interventions that include at least two distinct components
that
are implemented in at least two
different types of settings (e.g., schools, recreation areas) or that reach the entire community (e.g., mass media campaigns).
c State laws in Oregon and Washington allow minors younger than age 18 years to use indoor tanning facilities with a doctor's prescription.
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73. New York State Legislature. Use of sunscreen. Article 19: Section 907. http·//public.leginfo.state nv.us/LAWSSEAF.cei?
QUERYTYPE=LAWS+&QUERYDATA=@SLEDNOTlAl9+&LIST=SEA2+&BROWSER=EXPLORER+&TQKEN=34261658+&TARGET=YIEW.
Accessed May 2, 2014.
74. State of California. SCR 25, Speier. Resolution chapter I 05. Employer safety practices. 2005, http-//www.legjnfo ca.iwylpub/05-06/bill/sen/sb 0001-
0050/scr 25 bill 20050906 chaptered.html, Accessed February 3, 2014.
75. Arizona Department of Health Services. SunWise Skin Cancer Prevention School Program. Arizona Department of Health Services website.
http://www.az4hs.iwyiphsisunwisel Accessed July 17, 2013.
76. State of New York. New York education law 804. Title I, Article 17. http:/lpublic.leginfo.state.ny.us/LAWSSEAF.cgj?
QUERYIYPE=LAWS+&OUERYDATA=$$EDN804$$@TXEDN0804+&LIST=SEA7+&BROWSER""EXPLORER+&TOKEN=5!461778+&TARGET=VIEW.
Accessed September 9, 2013.
77. Kentucky General Assembly. 158.30 I Legislative findings on skin cancer risks: schools encouraged to educate students on risks of exposure to ultraviolet rays.
2006. http://www.lrc.ky.gov/Statuteslstatute.aspx?id=3496. Accessed September 9, 2013.
78. State of New York. New York Labor Law Article 7, 218-A.http://pµblideginfo.statenv.us/LAWSSEAF.cgi?QUERYWE=LAWS+&
QUERYDATA=$$LAB218-A$$@TXLAB0218-A+&LIST=SEA2+&BROWSER=EXPLORER+&TOKEN=51461778+&JARGET=VIEW. Accessed
September IO, 2013.
79. National Conference of State Legislatures. Indoor tanning restrictions for minors-a state-by-state comparison. National Conference of State Legislatures
website. http://www.ucsl.org/issues-researchlhealth/jndoor-tanuing-restrictions.a§Px. Accessed May 23, 2014.
80. Minnesota State Legislature, Minnesota House of Representatives. H.F. 2402 3rd Engrossment-88th Legislature (2013-2014). Omnibus health and human
services policy bill. 2014.
\..'..)/
81. AIM at Melanoma. 2014 indoor tanning legislation, 2014 state by state comparison. AIM at Melanoma website. http://www.aimatmelanoma.orglen/aim-for-a·
516
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The Surgeon General's Call to Action
to
Prevent Skin Cancer
I
SurgeonGaneral .gov
gire!legislative-accomplishments-in-melanoma/20
J4-jndoor-tannjog.hrrol.
Accessed May 23, 2014.
82. Colorado Department of Public Health and Environment. Artificial tanning frequently requested information. Colorado Department of Public Health and
Environment website. https·//www colorado gov/pacific/cdphe/artificial-tanning-freQ.Uently-req_uested-inforrnation Accessed July 11, 2014.
83. Kansas Board of Cosmetology. Statutes and Regulations. Kansas Board of Cosmetology website.
htt1r //www accesskansas.orglkboc/StatsandRegs.htm#tanninglaws. Accessed July 11, 2014.
84. Iowa Department of Public Health. Tanning facilities. Iowa Department of Public Health website.http://wwwjd.ph.state.ia,us/Tanning/. Accessed September 30,
2013.
85. Iowa Department of Public Health. Iowa Administrative Code, chapter 46. Minimum requirements for tanning facility. 2008.
http://www.legis.iowa govldocs/ACQichapter/641 .46,pdf. Accessed January 30, 2014.
86. Guy GP, Berkowitz Z, Jones SE, et al. State indoor tanning laws and adolescent indoor tanning.
Am
J
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87. U.S. Food and Drug Administration, U.S. Department of Health and Human Services. Sunscreen drug products for over-the-counter human use. Code ofFederal
Regulations Title 21, Volume 76, Number 117, Parts 201, 310, and 352. (June 17, 2011).
Fed&gisL
2011. http://www.imo gov/fdzys/pkg/FR-201!-06-
17/btm!/2011-14766.htm.
88. U.S. Food and Drug Administration. FDA's medical devices: classify your medical device. U.S. Food and Drug Administration website.
http://www.fda.gov/MedicalDeyjces/DeviceReflUlationandGuidance/Ovcrview/ClassjfYYou.rDevice/dcfaJ!ltl:!!m,, Accessed June 4, 2013.
89. U.S. Food and Drug Administration. Rule. General and plastic surgery devices: reclassification of ultraviolet lamps for tanning, henceforth
to
be known as
sunlamp products and ultraviolet lamps intended for use in sunlamp products.
Fed Regi-st.
20 l 4;79:31205-31214.
90. U.S. Food
and
Drug Administration. FDA news release: FDA to require warnings on sunlamp products. U.S. Food and Drug Administration website.
http://www.fcla.gov/NewsEvents!Newsroom/PressAnnovncements/w;m399222.htm. Accessed June 4, 2014.
91. Community Preventive Services Task Force. Recommendations
to
prevent skin cancer by reducing exposure to ultraviolet radiation.
Am
J
Prev Med.
2004;27(5):467-470.
92. Shih ST, Carter
R,
Sinclair C, Mihalopoulos C, Vos T. Economic evaluation of skin cancer prevention
in
Australia.
Prev Med.
2009;49(5):449-453.
93. Pawlak MT, Bui M, Amir M, Burkhardt DL, Chen AK. Dellavalle RP. Legislation restricting access
to
indoor tanning throughout the world.
Arch Dennatol.
2012;148(9):1006-1012.
94. Sinclair C, Makin
JK.
Implications of lessons learned from tobacco control for tanning bed reform.
Prev Chronic Dis.
2013;10:e28.
616
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mi
Centers for Disease
Control and Prevention
. CDC 24/7:
Saving
Lives.
Protecting People™
Indoor Tanning Is Not Safe
Jsing a tanning bed, booth, or sunlamp to get tan is called
indoor
tanning.
Indoor tanning can cause skin cancers including melanoma
the deadliest type of skin cancer), basal cell carcinoma, and
;quamous cell carcinoma. Exposure to ultraviolet (UV) radiation also
:an cause cataracts and cancers of the eye (ocular melanoma).
)angers of Indoor Tanning
ndoor tanning exposes users to two types of UV rays, UVA and UVB,
ivhich damage the skin and can lead to cancer. Indoor tanning is particularly dangerous for younger users;
)eople who begin indoor tanning during adolescence or early adulthood have a higher risk of getting
nelanoma. This may be due to greater use of indoor tanning among those who begin tanning at earlier ages.
:very time you tan you increase your risk of getting skin cancer, including melanoma. Indoor tanning also-
• Causes premature skin aging, like wrinkles and age spots.
• Changes your skin texture.
• Increases the risk of potentially blinding eye diseases, if eye protection is not used.
=acts About Indoor Tanning
fanning indoors is not safer than tanning in the sun.
ndoor tanning and tanning outside are both dangerous. Although indoor tanning devices operate on a timer,
:he exposure to UV rays can vary based on the age and type of light bulbs. Indoor tanning is designed to give
rou high levels of UV radiation in a short time. You can get a burn from tanning indoors, and even a tan
ndicates damage to your skin.
!\ base tan is not a safe tan.
\tan is the body's response to injury from UV rays. A base tan does little to protect you from future damage
:o your skin caused by UV exposure. In fact, people who indoor tan are more likely to report getting
;unburned.
lhe best way to protect your skin from the sun is by using these tips for skin cancer prevention.
ndoor tanning is not a safe way to get vitamin D.
\lthornlh
it
is imoortant to e:et enoue:h vitamin D. (htto://ods.od.nih.gov/factsheets/vitamind/) the safest way
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:o do so is through what you eat. Tanning harms your skin, and the amount of UV exposure you need to get
:!nough vitamin Dis hard to measure because it is different for every person and also varies with the
rVeather, latitude, altitude, and more.
Statistics
itudies have shown consistently that indoor tanning increases a person's risk of getting skin cancer,
ncluding melanoma.
• A
meta-analysis (http://www.ncbi.nlm.nih.gov/omc/articles/PMC3049418/J
(a research study that looks
at data from other studies) by Boniol and colleagues in 2012
(htt12://www.ncbi.nlm.nih.gov/pubmed/22833605) combined findings from studies conducted in Europe,
Australia, and the United States. The meta-analysis shows a link between indoor tanning and melanoma.
• Another meta-analysis published in 2014 by Colantonio and colleagues
(http://www.ncbi.nlm.nih.gov/pubmed/24629998) reconfirmed the association between indoor tanning
and melanoma, and also found that newer tanning beds were not safer than older models.
• A 2014 study by Wehner and colleagues (http://}NWW.ncbi.nlm.nih.gov/pubmed/24477278) estimated
that more than 400,000 cases of skin cancer may be related to indoor tanning in the United States each
year-causing 245,000 basal cell carcinomas, 168,000 squamous cell carcinomas, and 6,000 melanomas.
• A 2010 study by Lazovich and colleagues (http://www.ncbi.nlm.nih.gov/pubmed/20507845} in the
United States found that the risk of getting melanoma increased the more years, hours, or sessions spent
indoor tanning.
~ccording
to the data from the 2013 Youth Risk Behavior Surveillance System. (http://www.cdc.gov/yrbss/l
nany teens are indoor tanning, including-
• 13% of all high school students.
• 20% of high school girls.
• 27% of girls in the 12th grade.
• 31% of white high school girls.
~ccording
to the 2010 National Health Interview Survey. (http://www.cdc.gov/nchs/nhis.htm) indoor
:ariners tended to be young, non-Hispanic white (NHW) women. A closer look at the data showed the
:allowing rates of indoor tanning among NHWwomen-
• 32% of those aged 18 to 21 years.
• 30% of those aged 22 to 25 years.
• 22% of those aged 26 to 29 years.
• 17% of those aged 30 to 34 years.
-fealthy People 2020 Objectives for Indoor Tanning
-lealthy People (http://healthypeople.gov/2020/l provides science-based, 10-year national objectives
fofiiJ
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=-· . --.
--r=--··
--·
'http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicld=5) including-
·~~.-
.. -
"'···o
-··- ... --·-·· -· - ..... ····-· .. ---··-· ·
·---· ...
··r
· --.-·- - - - - ··-- - -
• Reduce the proportion of adolescents in grades 9 through 12 who report indoor tanning to 14.0%.
• Reduce the proportion of adults aged 18 years and older who report indoor tanning to 3.6%.
Indoor
Tanning Policies
ndoor tanning is restricted in some areas, especially for minors.
Jn ited States
:alifornia, Delaware, Hawaii, Illinois, Louisiana, Minnesota, Nevada, New Hampshire, North Carolina,
)regon,* Texas, Vermont, Washington,* and some cities and counties have banned indoor tanning by minors
rounger than 18 years. For the latest information, see the National Conference of State Legislatures'
ranning Restrictions for Minors: A State-by-State Comparison
http://www.ncsl.org/lssuesResearch/Health[fanningRestrictionsforMinorsstatelawssummary/tabid/1439
Ul
and AIM at Melanoma's 2014 Indoor Tanning Legislation. (http://www.aimatmelanoma.org/en/aim-for-a-
:ure/legislative-accomplishments-in-melanoma/2014-indoor-tanning.htmll
The state laws in Oregon and Washington contain an exemption which allows people younger than age 18
:o tan-with a doctor's prescription.
:oc
research (http://www.ncbi.nlm.nih.gov/pubmed/24524515) shows that states with indoor tanning
aws that include age restrictions had lower rates of indoor tanning among minors.
rhe U.S. Food and Drug Administration has proposed a rule
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm350790.htm) to protect youth from the risks of
ndoor tanning devices by restricting use by minors younger than 18 years. This proposed rule also would
·equire indoor tanning facilities to inform adult users about the health risks of indoor tanning and to obtain
1
signed risk acknowledgement from these users. The agency also is proposing a second rule that would
·equire manufacturers and indoor tanning facilities to take more actions to help improve the overall safety
>f indoor tanning devices to protect adult consumers.
nternationa I
• Brazil and Australia have banned indoor tanning.
• Austria, Belgium, Finland, France, Germany, Iceland, Italy, Norway, Portugal, Spain, and the United
Kingdom have banned indoor tanning for people younger than age 18.
>age last reviewed: January 5, 2016
>age last updated: January 5, 2016
:ontent source: Division of Cancer Prevention and Control, (http://www.cdc.gov/cancer/dcpdaboutl) Centers for Disease
:ontrol and Prevention (http://www.cdc.gov/)
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Evaluation of Indoor Tanning Health Claims
Prepared by:
Sophie Julia Balk, M.D.
David Fisher, M.D., Ph.D.
Alan C. Geller MPH, RN
Martin A. Weinstock, M.D., Ph.D.
Prepared for:
New York State Office of the Attorney General
March 2015
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Table of Contents
Introduction ...................................................................................................................................... 1
Prominent Organizations Deem Indoor Tanning a Cancer Risk and Advocate Banning
Minors from Indoor Tanning ........................................................................................................... 2
Risks of Indoor Tanning ..................................................................................................................4
Indoor Tanning Increases Skin Cancer Risk ................................................................................ 4
Youth, and Young Women in Particular, Are Vulnerable ........................................................... 8
Indoor Tanning Can Lead to Premature Skin Aging, Immune Suppression, and Eye
Damage, Including Cataracts and Cancer ............................................................................. 13
Indoor Tanning Can Be Addictive ............................................................................................. 14
Lack of Health Benefits Associated With Indoor Tanning ........................................................... .16
Indoor Tanning Is Not a Safe Source of Vitamin D ................................................................... 16
Indoor Tanning Does Not Prevent or Treat Cancer or Heart Disease ........................................ 20
Indoor Tanning Has Not Been Shown
to
Treat Asthma ............................................................ 23
Indoor Tanning Is Not an Established or Safe Way
to
Lower Blood Pressure or Treat
Hypertension ......................................................................................................................... 23
Indoor Tanning Does Not Prevent or Treat Diabetes ................................................................. 24
Indoor Tanning Does Not Prevent Blood Clots ......................................................................... 25
Indoor Tanning Does Not Improve Muscle Efficiency .............................................................. 26
Indoor Tanning Does Not Help Prevent Alzheimer's ................................................................ 26
Indoor Tanning Is Not a Safe Way to Avoid UV Risks or Overexposure ................................. 26
Indoor Tanning Does Not Safely Provide Psychological Benefits ............................................ 28
Indoor Tanning Is Not a Safe Way to Treat "Problem Skin" ..................................................... 28
Unlimited Packages Encourage Frequent Tanning .................................................................... 29
Conclusions .................................................................................................................................... 30
Author Background........................................................................................................................ 30
Sophie Julia Balk, M.D .............................................................................................................. 30
David E. Fisher, M.D., Ph.D ...................................................................................................... 31
Alan C. Geller MPH,
RN" ...........................................................................................................
32
Martin A. Weinstock, M.D., Ph.D ............................................................................................. 32
1
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This report was prepared for the New York State Office of the Attorney General.
It
examines the risks associated with indoor tanning and evaluates the veracity of health claims
presented by the indoor tanning industry to promote indoor tanning. The report is jointly
authored by Sophie Julia Balk, M.D.; David E. Fisher, M.D., Ph.D.; Alan C. Geller, MPH, RN;
and Martin A. Weinstock, M.D., Ph.D. This report is based upon their knowledge and expertise
as well as the materials referenced herein.
Introduction
I.
"Indoor tanning" is the use of tanning beds or tanning booths to tan the skin for
cosmetic purposes.
1
Over the past several decades, indoor tanning has become increasingly
popular. Each day, over one million people in the United States indoor tan.
2
Tanning salons are
ubiquitous; they now outnumber Starbucks or McDonalds in large U.S. urban areas.3
2.
Tanning beds contain sunlamps, which expose users to ultraviolet
(UV)
radiation
that is much stronger than natural sunlight-up to fifteen times more intense than the sun,
frequently resulting in buming.
4
The U.S. Food and Drug Administration (FDA) has approved
sunlamps for a very narrow purpose--"to tan the skin."
5
The FDA has
not
approved tanning
beds for "health" purposes.
Tanning beds are designed to be used lying down, while tanning booths are designed to be used standing up.
Tanning beds are often called sunbeds in Europe.
Jody
A.
Levine et al.,
The Indoor UV Tanning Industry: A Review ofSkin Cancer Risk, Health Benefit Claims,
&
Regulation,
53
J.
Am.
Acad. Dermatology 1038, 1039 (2005); S. Elizabeth Whitmore et al.,
Tanning Salon
Exposure
&
Molecular Alterations,
44 J. Am. Acad. Dermatology 775, 775 (2001).
Katherine D. Hoerster et al.,
Density ofIndoor Tanning Facilities in 116 Large U.S. Cities,
36 Am. J. Preventive
Med. 243 (2009).
World Health Org., Int'l Agency for Research on Cancer, Working Group on Artificial Ultraviolet
(UV)
Light
&
Skin Cancer,
The Ass 'n of Use of Sunbeds With Cutaneous Malignant Melanoma
&
Other Skin Cancers: A Systemic
Review,
120 Int'l J. Cancer, 1116 (2006); Beat Gerber et
al.,
Ultraviolet Emissions Spectra of Sunbeds,
76
Photochemistry
&
Photobiology 6, 666 (2002).
5
4
1
2
3
21 C.F.R.
§
878.4635 (2014).
1
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3.
As will be explained in more detail below, indoor tanning significantly increases
the risk of skin cancer including melanoma, the type of skin cancer responsible for the most
deaths. The harmful effects of UV exposure increase over time. Thus, indoor tanning devices
pose a greater risk for children and teens by boosting overall lifetime exposure. Indoor tanning
also increases the risk of eye damage and wrinkles, changes skin texture, and can be addictive.
4.
Despite the serious and well-established health risks, however, indoor tanning
salons and trade associations continue to aggressively market and promote indoor tanning as
safe, often focusing their advertising on teenage girls and young women.
6
What is more, many
salons and trade associations assert an array of purported health benefits in their advertising,
including on websites and social media. This is true in New York State where tanning salons,
including Total Tan, Inc. and Portofino Sun Center, have claimed that indoor tanning is a safe
way to obtain vitamin D and prevent and treat cancer. These salons have also asserted that
indoor tanning has physiological and psychological benefits, reduces blood pressure, and treats
asthma. As detailed below, these and other health benefit claims are not supported by generally
accepted science.
Prominent Organizations Deem Indoor Tanning a Cancer Risk
and Advocate Banning Minors from Indoor Tanning
5.
Recognizing the high cancer risk associated with indoor tanning, in 2009, the
World Health Organization's International Agency for Research on Cancer reclassified indoor
U.S. House of Representatives Comm. on Energy
&
Commerce Minority Staff,
Investigative Report False
&
Misleading Health Info. Provided to Teens
By
the Indoor Tanning Industry
at 1, 13, 15 (2012)
available at
http://democrats.energycommerce.house.gov/sites/default/files/documents/False-Health-Info-by-Indoor-Tanning-
lndustry-2012-2-1.pdf (last visited Jun. 10, 2014);
see also
Scott Freeman et al.,
UV Tanning Advertisements in High
School Newspapers,
142 Archives of Dermatology 460 (2006),
available at
http://archdenn.jamanetwork.com/
article.aspx?articleid=404557 (last visited Jun. 10, 2014).
6
2
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tanning devices from "probable carcinogen" (Group 2A) to its highest risk level of "carcinogenic
to
humans" (Group 1) placing tanning beds in the same category as cigarettes.
7
6.
In July 2014, the U.S. Surgeon General issued a call to action to various sectors
across the nation to address skin cancer as a major public health problem.
8
A key goal of the call
to action is to reduce the harm caused by indoor tanning, which is causing an estimated 400,000
cases of skin cancer per year and is an entirely preventable method of exposure.
7.
9
The leading national dermatological organization, the American Academy of
Dermatology, supports the World Health Organization and also calls for an outright ban on the
production and sale of indoor tanning equipment for non-medical purposes.
10
The American
Academy of Pediatrics, an organization of more than 60,000 pediatricians, pediatric surgeons
and pediatric subspecialists, calls for banning minors from tanning indoors.
11
The American
Medical Association calls for banning minors from tanning indoors.
12
8.
The following leading national medical organizations recognize the high cancer
13
risk associated with indoor tanning:
Fatiha El Ghissassi et al. on behalf of the World Health Org., Int'l Agency for Research on Cancer,
Special Report:
Policy, A Review ofHuman Carcinogens-Part D: Radiation,
10 Lancet Oncology 751, 752 (2009)
available at
http://download.thelancet.com/pdfs/joumals/lanonc/PIIS 147020450970213X.pdf?id=eaa-jLrN5V-s-hFRlmmAu
(last visited Jun. 11, 2014).
U.S. Dep't of Health
&
Human Servs. Office of the Surgeon General,
The Surgeon General's Call to Action to
Prevent Skin Cancer
(2014), http://www.surgeongeneral.gov/library/calls/prevent-skin-cancer/call-to-action-
prevent-skin-cancer. pdf (last visited Aug. 8, 2014).
9
7
8
Id.
at57.
10
Am.
Acad. of Dermatology,
Indoor Tanning,
http://www.aad.org/media-resources/stats-and-facts/prevention-and-
care/indoor-tanning (last visited Feb. 2, 2015).
Am.
Acad. of Pediatrics,
A.AP
Recommendations on Limiting Sun Exposure in Children and Supporting
Legislation to Prohibit Salon Tanning by Minors,
http://www.aap.org/en-us/about-the-aap/aap-press-
roorn/pages/AAP-Recommendations-on-Limiting-Sun-Exposure-in-Children-and-Supporting-Legislation-to-
Prohibit-Salon-Tanning-by-Minors.aspx (last visited Aug. 6, 2014).
Carolyne Krupa,
Cancer Prevention Efforts Target Tanning Salons,
http://www.arnednews.com/
article/20110321/health/303219947/4/ (Mar. 21, 2011)
12
11
Am.
Acad. of Dermatology,
Nat'l Health Care Orgs. Unite to Warn the Public About the Dangers ofIndoor
Tanning,
http://www.aad.org/stories-and-news/news-releases/national-health-care-organizations-unite-to-warn-the-
13
3
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American Medical Association
Centers for Disease Control and Prevention
American Cancer Society
American Academy of Dermatology
American Academy of Pediatrics
American Academy of Ophthalmology
American Osteopathic Association
Melanoma Research Foundation
National Council on Skin Cancer Prevention
American College of Physicians
The Skin Cancer Foundation
American Congress of Obstetricians and
Gynecologists
Risks of Indoor Tanning
Indoor Tanning Increases Skin Cancer Risk
9.
Skin cancer, which includes melanoma, basal cell carcinoma, and squamous cell
carcinoma, is the most common of all cancers in the United States with more
than
3.5 million
skin cancers in over 2 million people diagnosed annually.
14
Over the past 30 years, more people
have been diagnosed with skin cancer than all other cancers combined.
15
Over the course of
their lifetimes, it has been estimated that one in five Americans will develop skin cancer.
16
Every year in New York State alone, approximately 3,500 people are diagnosed with melanoma
and 100,000 people are diagnosed with basal or squamous cell carcinoma.
17
public-about-the-dangers-of-indoor-tanning (May 3, 2011) (last visited Jun. 10, 2014); Ctrs. for Disease Control
&
Prevention,
Is Indoor Tanning Safe?,
http://www.cdc.gov/cancer/skin/basic_info/indoor_tanning.htm (last visited
Jun. 10, 2014).
Howard W. Rogers, Martin A. Weinstock, Ashlynne R. Harris, Michael R. Hinckley, Steven R. Feld.man, Alan
B.
Fleischer
&
Brett M. Coldiron,
Incidence Estimate ofNonmelanoma Skin Cancer in the U.S., 2006,
146 Archives of
Dermatology 283 (2010),
available at
http://archderm.jamanetwork.com/article.aspx?articleid=209782 (last visited
Jun. IO, 2014).
Robert S. Stem,
Prevalence ofa History ofSkin Cancer in 2007 Results ofan Incidence-Based Model,
146
Archives of Dermatology 279 (2010),
available at
http://archderm.jamanetwork.com/article.aspx?articleid=209761
(last visited Jun. 10, 2014).
16
14
15
Id.
N.Y. State Dep't of Health, N.Y. State Cancer Registry,
Skin Cancer in N.Y. York State Sixth Ann. Rep. to the
Governor ofN.Y., the Temporary President ofthe Senate,
&
Speaker of the Assembly
(2013)
available at
http://www.health.ny.gov/statistics/diseases/cancer/skin/report/docs/2013_ report.pdf (last visited Jun. 10, 2014 ).
17
4
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10.
Melanoma is responsible for about 75% of skin cancer deaths.
18
One American
dies from melanoma every hour.
19
About 600 New Yorkers die from skin cancer each year and
77% of those deaths are attributed to melanoma.
20
Melanoma is the most common cancer for
young adults 25-29 years old and the second most common cancer for adolescents and young
adults 15-29 years old.
21
11.
Non-melanoma (also called keratinocyte) skin cancers such as basal cell and
squamous cell carcinoma are very common, but generally not fatal. They can lead to facial
deformity, disfigurement, and scarring, and can be costly
to
treat when they recur. Non-
melanoma skin cancers place burdens on our healthcare system, costing the United States $650
million annually.
22
12.
In
New York State, more than 10,000 outpatient surgeries for melanoma and non-
melanoma skin cancer are performed each year.
23
In
2012 alone, Medicaid patients in New York
State diagnosed with skin cancer cost $10.7 million.
24
Treatment of all types of skin cancer can
lead to scarring, large lesions, and particularly disfiguring treatments. Recognizing that indoor
Am. Cancer Soc'y,
Cancer Facts & Figures 2014
at 4, http://www.cancer.org/acs/groups/content/
@research/documents/webcontent/acspc-042151.pdf (last visited
Jun.
12, 2014).
19
20
21
18
Id.
at4.
Skin Cancer in
N.
Y. State, supra
footnote 17, at 18.
Cynthia Herzog et al.,
Chapter 5 Malignant Melanoma
in
CANCER EPIDEMIOLOGY IN OLDER ADOLESCENTS
&
YOUNG ADULTS 15 TO 29 YEARS
OF
AGE, INCLUDING SEER INCIDENCE
&
SURVIVAL: 1975-2000 at 53-57
cy./.
Archie Bleyer et
al.
eds., 2006),
available at
http://seer.cancer.gov/archive/publications/aya/aya_mono_
complete.pdf (last visited
Jun.
I 0, 2014).
Tejaswi Mudigonda et
al.,
The Econ. Impact ofNon-Melanoma Skin Cancer: A Review,
8
J.
Nat'l Comprehensive
Cancer Network 888 (2010).
See also
Burak Omiir Ca.kir at
al.,
Epidemiology & Econ. Burden ofNonmelanoma
Skin Cancer,
20 Facial Plastic Surgery Clinics of North
Arn.
419 (2012); Kun
Kim
et al.,
Econ. Burden of Resected
Squamous Cell Carcinoma of the Head &Neck in a U.S. Managed-Care Population,
14
J.
Med. Econ. 421 (2011),
available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219567/ (last visited Nov. 25, 2013).
23
24
22
Skin Cancer in
N.
Y. State, supra
footnote 17, at 17.
N.Y. State Office of the Attorney
General,
Medicaid Database (accessed Jan. 28, 2014).
5
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tanning leads to health care costs, Congress included a 10% tax on indoor tanning in the
Affordable Care Act.
25
13.
A systematic review estimated the years of potential life lost and the value of
productivity loss from morbidity and premature mortality resulting from melanoma and non-
melanoma skin cancer.
26
After extracting data from 16 relevant studies, the review estimated
that the average number of years of potential life lost per death was approximately 15 years for
melanoma and 10 years for non-melanoma skin cancer. The indirect costs attributable to
melanoma and non-melanoma skin cancer in one year were $76.8 million for morbidity
(including lost workdays, caregiver lost workdays, and restricted activity days), and ranged from
$1 billion to $3.3 billion for premature mortality. Therefore, skin cancer leads to significant
years of potential life lost and indirect costs associated with premature mortality and morbidity.
14.
Overwhelming evidence shows that indoor tanning causes skin cancer, and the
causal link between indoor tanning and skin cancer is generally accepted in the scientific
community. In a recent review of published studies, about 6,200 melanomas per year in the
United States were attributed to tanning beds along with nearly 245,000 basal cell cancers and
165,000 squamous cell cancers.
27
Another recent review estimated a 1.8% increase (95%
confidence interval of 0% to 3.8%) in risk of melanoma for each additional session of tanning
bed use per year.
28
Within that same review, based on 13 informative studies, individuals who
25
26 U.S.C.
§
5000B; 155 Cong. Rec. 813,745 (Dec. 22, 2009) (statement of Senator Jack Reed).
Gery P. Guy
&
Donatus U. Ekwueme,
Years ofPotential Life Lost
&
Indirect Costs ofMelanoma
&
Non-
Melanoma Sldn Cancer: A Systematic Review of the Literature,
10 Phannacoeconomics 863-74 (2011 ).
Mackenzie R. Wehner et al.,
Int'/ Prevalence ofIndoor Tanning, A Systematic Review
&
Meta-Analysis,
150
JAMA Dermatology 390, 398, Table 2 (2014). "[T]he extremely high incidence of skin cancer means that there are
more skin cancer cases attributable to indoor tanning than lung cancer cases attributable to smoking."
Id.
Mathieu Boniol et al.,
Cutaneous Melanoma Attributable to Sunbed Use: Systematic Review
&
Meta-Analysis,
2012 BMJ 1, 3 (Jul. 24, 2012),
available at
http://www.bmj.com/content/345/bmj.e4757 (last visited Apr. 20, 2015).
28
27
26
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first used tanning beds before the age of 35 had an estimated 59% greater risk of melanoma
compared to those who did not use tanning beds.
29
15.
Both animal studies and epidemiological studies show the link between UV
exposure and melanoma.
30
Many melanomas occurring in indoor tanners--even in a country
with large populations exposed to intense sun such as Australia-were more attributable to
indoor tanning than to the sun.
31
Use of cutting edge genome sequencing technology has
indicated that the genomic DNA of human melanomas is riddled with thousands of"UV
signature" mutations, which represent chemical errors within melanoma cells that are known
to
be caused by UV radiation (di-pyrimidine mutations).
32
This constitutes direct experimental
evidence showing the link between UV exposure and skin cancer.
16.
It
should be noted that multiple genetic and environmental factors have been
implicated in the development of skin cancer. There are several known genetic conditions that
predispose a person to develop melanoma, and there are individuals who develop melanoma on
non-UV exposed areas, such as inside the mouth or
in
the genital areas.
In
addition, certain
individuals may be predisposed to melanoma because of immunosuppression, preventing them
29
Id.;
Mathieu Boniol et al.,
Corrections, Cutaneous Melanoma Attributable to Sunbed Use: Systematic Review
&
Meta-Analysis,
2012 BMJ (Dec. 13, 2012),
available at
http://www.bmj.com/content/345/hmj.e8503 (last visited
Apr. 20, 2014).
World Health Org., Int'l Agency for Research on Cancer,
Solar
&
Ultraviolet Radiation: Summary ofData
Reported
&
Evaluated, 55
IARC Monographs on the Evaluation of Carcinogenic Risks to Humans at 5-6,
available
at
http://monographs.iarc.fr/ENG/Monographs/vol55/volume55.pdf (last visited Nov. 25, 2013); DeAnn Lazovich,
Rachel Vogel, Marianne Berwick, Martin Weinstock, Kristen Anderson, & Erin Warshaw,
Indoor Tanning
&
Risk
ofMelanoma: A Case-Control Study in a Highly Exposed Population,
l 9 Cancer Epidemiology, Biomarkers
&
Prevention 1557 (2010),
available at
http://cebp.aacrjournals.org/content/19/6/1557.long (last visited Jun.
ll,
2014 );
Martin
A.
Weinstock & David E. Fisher,
Indoor Ultraviolet Tanning: What the Data Do
&
Do Not Show Regarding
Risk ofMelanoma
&
Keratinocyte Malignancies,
8 J. Nat'l Comprehensive Cancer Network 867 (20 I 0).
Anne E. Cust et
al.,
Sunbed Use During Adolescence
&
Early Adulthood Is Associated With Increased Risk of
Early-Onset Melanoma,
128 Int'l J. Cancer 2425 (2011),
available at
http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2993823/ (last visited Jun. 11, 2014).
Eran Rodis et al.,
A Landscape ofDriver Mutations in Melanoma,
150 Cell 251:-63 (2012),
available at
http://ac.els-cdn.com/S0092867412007787/1-s2.0-S0092867412007787-main.pdf1_ tid=a93493cc-aee7-11 e3-862a-
00000aab0f26&acdnat= 1395179755_fa36879d742a45c9ea8b2cf908ad3c08 (last visited Jun. 11, 2014).
32
30
31
7
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from mounting the normal immunologic defense against early tumor development. However,
these predisposing factors do not negate the overwhelming evidence of the role of UV exposure
in the development of most melanomas, and the role of indoor tanning in increasing that risk.
17.
Sunlamp use also increases the risk of non-melanoma skin cancers. Exposure to
indoor tanning was associated with a 67% higher risk for squamous cell carcinoma and a 29%
higher risk for basal cell carcinoma in a review and meta-analysis.
33
In another study,
individuals who indoor tanned were at least two and a halftimes more likely to develop
squamous cell carcinoma and one and a halftimes more likely to develop basal cell carcinoma.
Youth, and Young Women in Particular, Are Vulnerable
34
18.
Efforts to market indoor tanning tend to target young women in particular, and the
data show that these efforts have been successful-70% of the one million people who indoor
tan each day are Caucasian females between 16 and 49 years of age.
35
Children are most
susceptible to marketing efforts and are also at particular risk for disease, as the evidence clearly
demonstrates that the earlier one indoor tans, the greater the risk for skin cancer in later years.
36
19.
According to the 2011 Youth Risk Behavior Study from the Centers for Disease
Control and Prevention, 20.9% of all U.S. female high school students have indoor tanned in
Wehner et al.,
supra
footnote 27;
see also
Leah M. Ferrucci et al.,
Indoor Tanning
&
Risk ofEarly-Onset Basal
Cell Carcinoma,
67
J.
Am. Acad. Dermatology 552 (2011) ("Ever indoor tanning was associated with a 69%
increased risk of early-onset BCC [basal cell carcinoma].").
Margaret
R.
Karagas, Virginia A. Stannard, Leila A. Mott, Mary Jo Slattery, Steven
K.
Spencer
&
Martin A.
Weinstock,
Use of Tanning Devices
&
Risk ofBasal Cell
&
Squamous Cell Skin Cancers,
94
J.
Nat'l Cancer Inst.
224 (2002);
see also
World Health Org.,
supra
footnote 4; Marit B. Veiernd et al.,
Host Characteristics, Sun
Exposure, Indoor Tanning
&
Risk ofSquamous Cell Carcinoma ofthe Skin,
135 Int'l
J.
Cancer 2, 413-22 (2014).
Jody A. Levine et al.,
The Indoor UV Tanning Industry: A Review ofSkin Cancer Risk, Health Bene.fit Claims,
&
Regulation,
53
J.
Am
Acad. Dermatology 1038, 1039 (2005).
36
35
34
33
See, e.g.,
Wehner et al.,
supra
footnote 27; Boniol et al.,
supra
footnote 28.
8
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2011 compared with 6.2% ofmales.
37
Rates were highest among female 17-year-old high school
students (27.9%) and older students (31.5%).
38
20.
As indoor tanning has gained popularity, especially among young women who are
targeted by tanning salons, there has been an associated increase in rates of melanoma. National
Cancer Institute data was used to investigate changes in melanoma incidence between 1973 and
2004. During that time period, the age-adjusted annual incidence of melanoma among women
increased by more than 2.5 times.
39
In contrast, during the same time period, the age-adjusted
annual incidence of melanoma among young men only increased by 1.6 times. In the absence of
data that shows marked differences in outdoor sun protection between high school males and
females, the gender disparity in indoor tanning further supports the conclusion that high rates and
frequent use of indoor tanning by women is the leading cause of increased melanoma rates in
women relative to young men.
21.
Because scientific evidence shows that indoor tanning is particularly dangerous
for younger individuals, the American Academy of Pediatrics states, "Tanning salons are not
safe and should not be used by teenagers or others."
40
The U.S. Preventative Task Force-an
esteemed panel of independent national experts in prevention and medicine that works to
improve the health of all Americans by making evidence-based recommendations about clinical
preventive services-recommends counseling children, adolescents, and young adults (aged 10
Gery P. Guy
et
al.,
Indoor Tanning Among High School Students in the United States, 2009 & 2011,
JAMA
Dermatology (2014);
see also
Ctrs. for Disease Control
&
Prevention,
Youth Risk Behavior Surveillance
-
United
States, 2011,
Morbidity
&
Mortality Weekly Report (June 8, 2012),
available at
http://www.cdc.gov/mmwr/
preview/mmwrhtmVss6104al.htm (last visited Jun. 18, 2014).
38
37
Id.
39
Mark
P.
Purdue et al.,
Recent Trends in Incidence of Cutaneous Melanoma Among U.S. Caucasian Young Adults,
128
J.
Investigative Dermatology 2908 (2008).
40
Am.
Acad. of Pediatrics,
Ultraviolet Radiation
in
PEDIATRIC ENVIRONMENTAL HEALTH at
606 (Ruth
A.
Etzel
&
Sophie J. Balk eds., Oct. 2012).
9
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to 24 years) who have fair skin about minimizing their exposure to UV radiation to reduce risk
for skin cancer.
41
22.
Earlier exposure to sunlamps worsens later outcomes, and exacerbates the risk of
later cancers.
42
Those who begin indoor tanning before they are 35 years old have an estimated
59% higher risk of melanoma than those who do not.
43
In one study from Australia, among 18 to
29 year olds who have ever indoor tanned and were diagnosed with melanoma, 76% of those
melanoma cases were attributable to indoor tanning.
44
Indoor tanning at younger ages also
affects basal cell carcinoma risk. A recent study shows that there is a significantly higher risk of
developing basal cell carcinoma for individuals who used tanning beds during high school and
college in comparison to the ages of 25 and 35 years.
45
23.
The number of teenage girls that use indoor tanning facilities is particularly
alarming. Nearly all studies agree that about one third of white teenage girls use tanning beds,
now far eclipsing cigarette use among the same age group.
46
Girls are six times more likely than
boys to use tannirig beds, and 40% of girls who use tanning beds used them 10 or more times in
the past year.
47
The most typical adolescent indoor tanning patron is a teenage girl between the
ages of 15 and 18 with a skin type that either usually burns and minimally tans or has a skin type
Virginia
A.
Moyer on behalf of the U.S. Preventive Servs. Task Force,
Behavioral Counseling to Prevent Skin
Cancer: U.S. Preventive Servs. Task Force Recommendation Statement,
157 Annals Internal Med. 59, 60(2012),
available at
http://www.uspreventiveservicestaskforce.org/uspstfl l/skincancouns/skincancounsrs.pdf(last visited
Jun.
11, 2014}.
See, e.g.,
Philippe Autier,
Perspectives In Melanoma Prevention: The Case OfSunbeds,
40 European
J.
Cancer
2367 (2004);
Am.
Acad. of Pediatrics,
Ultraviolet Radiation, supra
footnote 40.
43
42
41
Boniol et
al.,
supra
footnotes 28, 29.
Cust et al.,
supra
footnote 31.
44
45
Mingfeng Zhang, Abrar
A.
Qureshi, Alan C. Geller, Lindsay Frazier, David J. Hunter,
&
Jiali Han,
Use of
Tanning Beds
&
Incidence ofSkin Cancer,
30 J. Clinical Oncology 1591 (2012).
Guy et al.,
supra
footnote 37.
Boniol et
al.,
supra
footnote 28.
46
47
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that sometimes burns and gradually tans.
48
According to a 2002 study of 10,000 children and
adolescents, 7% of 14 year-old Caucasian girls indoor
tan,
16% of 15 year-old Caucasian girls
indoor tan, and 35% of 17 year-old Caucasian girls indoor
tan.
49
Thus, the number of Caucasian
girls who use indoor tanning facilities thus
doubles
from age 14 to age 15, and then
doubles
again
from age 15 to age 17. Recent studies of adolescents report that rates of tanning bed use
among females are more than double those for males.
50
24.
Concerns about indoor tanning among young women are echoed in a 2012
investigative report published by the U.S. Congress House Committee on Energy and
Comrnerce.
51
The report is based on the results of telephone calls to 300 nationwide tanning
salons from Congressional staff that identified themselves as 16-year-old girls interested in
tanning for the first time. Some 90% of respondents employed by the tanning salons denied that
indoor tanning poses health risks and, when asked about skin cancer specifically, more than half
denied that indoor tanning would increase a fair-skinned teenager's risk of developing skin
cancer, dismissing the notion as "a big myth," "rumor," and "hype." Some 78% of tanning
salons claimed health benefits of tanning ranging from cancer prevention to providing vitamin D
to weight loss. The report concluded that tanning salons deny known risks of indoor tanning,
provide false information on the benefits of tanning, and
fail
to follow any recommendations on
tanning frequency. The report also concluded that tanning salons target teenage girls with
advertising and promotions such as student discounts and "prom," "homecoming," and "back-to-
school" specials that often include "unlimited" tanning packages.
Alan C. Geller, Graham Colditz, Susan Oliveria, Karen Emmons, Cynthia Jorgensen, Gideon N. Aweh,
A.
Lindsay
Frazier,
Use of Sunscreen, Sunburning Rates, and Tanning Bed Use Among More Than 10,000 U.S.
Children
and
Adolescents,
109 Pediatrics 1009, 1011-12 (2002).
49
50
51
48
Id.
Wehner et al.,
supra,
footnote 27.
U.S. House of Representatives,
supra,
footnote 6.
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25.
In response to the Congressional investigative report, the leading indoor tanning
trade association admitted that "it does highlight the need for us to reevaluate how our industry
can do a better job of ensuring that [trade association] member salons are providing accurate and
consistent information to their customers nationwide."
52
26.
Recognizing the dangers associated with indoor tanning, New York State
prohibits those under age 17 from indoor tanning and requires that 17 year olds obtain parental
consent before tanning. California, Illinois, Nevada, Oregon, Texas, Vermont, Minnesota
Louisiana, Hawaii, Delaware, Washington, the United Kingdom, Germany, Scotland, France,
and several Canadian provinces have banned indoor tanning for youth under 18.
53
Brazil and
Australia have banned indoor tanning beds for everyone, regardless of age.
54
27.
Likewise, the FDA recently placed additional restrictions on sunlamps,
strengthening protections by reclassifying sunlamp products from a low-risk device (class I) to a
moderate-risk device (class II).
55
Under this reclassification, effective September 2, 2014,
sunlamp manufactures will need pre-market certification to demonstrate that their products meet
certain performance testing requirements. In addition, the FDA is now requiring all sunlamp
products to have the following warning placed in a black box: "Attention: This sunlamp product
should not be used on persons under the age of 18 years." The FDA is also requiring that sales
Indoor Tanning Ass'n,
Report Misleads About Salon Claims
(Feb. 1, 2012)
available at
https://smarttan.com/news/index.php/report-misleads-about-salon-claims/ (last visited Jun. 11, 2014).
53
52
Nat'l Conference of State Legislatures,
Indoor Tanning Restrictions for Minors -A State-by-State Comparison
(updated May 2014),
available at
http://www.ncsl.org/research/health/indoor-tanning-restrictions.aspx (last visited
Jun. 11, 2014); Ctrs. for Disease Control
&
Prevention,
supra
footnote 13.
Ctrs. for Disease Control
&
Prevention,
supra
footnote 13; Cancer Council Australia,
Position Statement
Solariums,
http://wiki.cancer.org.au/prevention/Position_statement_-_ Solariums#Regulation (last visited Jun. 11,
2014) (Table 1 lists Australian state and territory legislation covering solarium use).
54
FDA,
FDA to Require Warnings on Sunlamp Products,
http://www.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/ucm399222.htm (May 29, 2014);
General
&
Plastic Surgery Devices: Reclassification of
Ultraviolet Lamps for Tanning, Henceforth
To
Be Known as Sunlamp Products
&
Ultraviolet Lamps Intended for
Use in Sunlamp Products,
79 Fed. Reg. 31,205 (Jun. 2, 2014) (amending 21 C.F.R. part 878).
55
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and promotional materials accompanying sunlamps contain the following warnings and
contraindications:
(A)
"Contraindication: This product is contraindicated for use on persons
under the age of 18 years."
"Contraindication: This product must not be used if skin lesions or open
wounds are present."
"Warning: This product should not be used on individuals who have had
skin cancer or have a family history of skin cancer."
"Warning: Persons repeatedly exposed to UV radiation should be
regularly evaluated for skin cancer."
(B)
(C)
(D)
Indoor Tanning Can Lead to Premature Skin Aging, Immune
Suppression, and
Eye
Damage, Including Cataracts and Cancer
28.
In
addition to increasing skin cancer risk, excessive exposure to UV radiation
during indoor tanning can lead to premature skin aging, immune suppression, and eye damage,
including cataracts and ocular melanoma.
56
29.
Indoor tanning leads to premature aging and wrinkles.
57
The immediate skin
swelling and tanning induced by UV light are a known response to tissue and DNA injury.
58
Over time, UV exposure leads to severe collagen loss and a weakening of the skin's elasticity,
resulting in sagging cheeks, deeper facial wrinkles, and skin discoloration.
59
Lim et al.,
Adverse Effects of UV Radiation From the Use ofIndoor Tanning Equip.: Time to Ban the Tan,
64
J.
Am. Acad. Dermatology 893, 895 (2011).
57
56
See e.g.,
Ctrs. for Disease Control
&
Prevention,
supra
footnote 13.
Denise K. Woo
&
Melody
J.
Eide,
Tanning Beds, Skin Cancer, and Vitamin D: An Examination of the Scientific
Evidence and Public Health Implications,
23 Dennatologic Therapy 61, 63 (2010); Yasuhiro Matsumura
&
Honnavara N. Ananthaswamy,
Toxic Effects of Ultraviolet Radiation on the Skin,
195 Toxicology
&
Applied
Pharmacology 298 (2004).
59
58
Sophie
J.
Balle
&
Am. Acad. of Pediatrics Council on Envtl. Health
&
Section on Dermatology,
Technical Report
Ultraviolet Radiation: A Hazard to Children
&
Adolescents,
127 Pediatrics 791, 792 (2011 ).
13
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30.
Indoor tanning leads to immune suppression.
60
The immune system protects the
body against organisms or substances that might cause disease. Immune suppression is an
impaired ability of the immune system to fight infection or disease.
31.
Indoor tanning can cause eye damage including photokeratitis, and long-term
exposure can increase the risk of developing cataracts.
61
Photokeratitis is a painful, but short-
term, eye condition caused by exposure of insufficiently protected eyes to UV rays. Symptoms
include eye tearing, pain, swelling of the eyelid, hazy or decreased vision and a feeling of having
sand in one's eye. A cataract is a clouding of the eye's natural lens, causing blurry vision or,
ultimately, blindness. Eye injuries, along with skin burns and syncope (fainting), caused by
indoor tanning results in thousands of emergency room visits per year.
62
Indoor Tanning Can Be Addictive
32.
Studies increasingly indicate that tanning can be addictive, particularly in younger
individuals. Early age of first indoor tanning use (between 13 and
1
7 years of age) was
significantly associated with both the presence of tanning addiction disorder and problematic
tanning behavior.
63
Excessive indoor tanning can be included in the spectrum of addictive
behaviors. 90 of 229 study participants who tanned indoors met the Diagnostic and Statistical
Manual of Mental Disorders criteria for addiction to indoor tanning.
64
Frequent tanners can
distinguish between UV tanning beds and non-UV beds (which were the same in every respect
60
61
Lim et al.,
supra
footnote
56.
Arn.
Optometric Ass'n,
UV Radiation, Protecting Your Eyes from Solar Radiation,
http://www.aoa.org/patients-
and-public/caring-for-your-vision/uv-protection (last visited Jun.
I 0, 2014).
Gery
P.
Guy et al.,
Indoor
Tannin~Related
Injuries Treated in a Nat 'l Sample of U.S. Hospital Emergency
Dep'ts,
JAMA
Internal Medicine Letters (Dec.
15, 2014).
62
Cynthia R. Harrington et al.,
Addictive-Like Behaviours to Wtraviolet Light Among Frequent Indoor Tanners,
36
Clinical
&
Experimental Dermatology 33, 35, 38
(2010).
Catherine E. Mosher
&
Sharon Danoff-Burg,
Addiction to Indoor Tanning: Relation to Anxiety, Depression,
&
Substance Use,
146
Archives of Dermatology
412 (2010).
64
63
14
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except for UV radiation), indicating that UV produces perceived behavioral effects known as
"reinforcing stimuli."
65
Some 21% of adolescents who tanned indoors more than one time in the
past year reported "difficulty in quitting" indoor tanning.
66
33.
Indoor tanning's addictive qualities have been linked to increased tanning
frequency
67
and endorphin release,
68
and individuals who stop abruptly can face withdrawal-like
symptoms of nausea and jitters.
69
Exposure to UV radiation from a commercial tanning bed
induced a response similar to nicotine, methamphetamine and cocaine.
70
A high percentage of
frequent indoor tanners experience behaviors consistent with other addictive disorders.
71
In
some individuals, indoor tanning has met Diagnostic and Statistical Manual criteria for a
substance-related disorder.
72
For example, some individuals continue to
tan
past the point
65
Steven R. Feldman et al.,
Ultraviolet Exposure Is a Reinforcing Stimulus In Frequent Indoor Tanners,
51 J. Am.
Acad. Dermatology 45 (2004).
Sarah Zeller et al.,
Do Adolescent Indoor Tanners Exhibit Dependency,
54
J.
Am. Acad. Dennatology 589-96
(2006).
Lisham Ashrafioun
&
Erin E. Bonar,
Tanning Addition
&
Psychopathology: Further Evaluation ofAm:iety
Disorders
&
Substance Abuse,
J. Am. Acad. Dermatology (2014),
available at
http://dx.doi.org/10.1016
/j.jaad.2013.10.057
(last visited Mar.
26, 2014).
Rutao Cui et al.,
Central Role ofp53 in the Suntan Response
&
Pathologic Hyperpigmentation,
128 Cell 853-64,
(2007); Gillian
L.
Fell, Kathleen C. Robinson, Jianren Mao, Clifford
J.
Woolf,
&
David E. Fisher,
Skin b-Endorphin
Mediates Addiction to UV Light,
157 Cell 1527-34 (2014).
Mandeep Kaur et al.,
Induction of Withdrawal-Like Symptoms in a Small Randomized, Controlled Trial of Opioid
Blockade in Frequent Tanners,
54 J. Am. Acad. Dermatology 709-11 (2006); Bridgit V. Nolan et al,
Tanning as an
Addictive Behavior: A Literature Review,
25 Photodermatology, Photoirnmunology
&
Photomedicine 12-19 (2009).
7
69
68
67
66
°
Cynthia R. Harrington et al.,
Activation ofthe Mesostriatal Reward Pathway With Exposure to Ultraviolet
Radiation (UVR) vs. Sham UVR in Frequent Tanners: A Pilot Study,
17 Addiction Biology 680-86 (2012).
Harrington et al. (2010),
supra
footnote 63; Cynthia R. Harrington et al.,
Activation of the Mesostriatal Reward
Pathway with Exposure to Ultraviolet Radiation (UVR) vs. Sham UVR
in
Frequent Tanners: A Pilot Study,
Addiction Biology 680, 681 (2011 ).
Nolan et al.,
supra
footnote 69; Molly M. W arthan et al.,
UV Light Tanning as a Type of Substance-Related
Disorder,
141 JAMA Dermatology 963-66 (2005),
available at
http://archderm.jamanetwork.com/
article.aspx?articleid=398011 (last visited Mar. 26, 2014);
72
71
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necessary to achieve their desired appearance.
73
Laboratory studies in mice have demonstrated
UV addiction behavior.
74
34.
Research into the addictive effects of indoor tanning "provide[s] a fascinating
potential explanation for the growth of the tanning bed industry despite the known health risk of
excessive UV exposure."
75
Lack of Health Benefits Associated With Indoor Tanning
Indoor Tanning Is Not a Safe Source of Vitamin D
35.
Many tanning salons assert through consumer-facing materials (including
websites and social media) that indoor tanning is a safe and efficient way to obtain vitamin D. A
number of salons have provided links on their websites to the Vitamin D Council website, which
asserts that vitamin D can be used to address a wide array of health conditions.
76
36.
As
explained in detail above, the risks of indoor tanning are substantial. Although
UV exposure of particular kinds, including some tanning beds, can increase production of
vitamin D, it is generally accepted that a dietary supplement and healthy diet can address vitamin
D deficiency or maintain adequate levels without the risks of indoor tanning. In June, the "FDA
acknowledged that UV radiation stimulates the body's production of vitamin D, however, there
are safer alternatives to obtain vitamin D other than the use of sunlamp products and UV lamps
73
74
Harrington et
al.
(2010),
supra
footnote 63.
Gillian
L.
Fell, Kathleen C. Robinson, Jianren Mao, Clifford J. Woolf,
&
David E. Fisher,
Skin /J-Endorphin
Mediates Addiction to UV Light, 151
Cell 1527-34 (2014),
available at
http://www.sciencedirect.com/
science/article/pii/S0092867414006114 (last visited Aug. 7, 2014); Hugo
A.
Tejeda
&
Antonello Bonci,
Shedding
"UV" Light on Endogenous Opioid Dependence,
151Cell1500 (2014).
Mary S. Brady,
Public Health
&
the Tanning Bed Controversy,
30 J. Clinical Oncology 1571 (2012),
available at
http://jco.ascopubs.org/content/30/14/1571 (last visited Jun. 23, 2014).
Vitamin D Council,
Health Conditions, available at
http://www.vitamindcouncil.org/health-conditions/ (last
visited Jun. 11, 2014).
76
75
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intended to be used in sunlamp products, for example, through an individual's diet.'m Likewise,
the American Academy of Pediatrics Policy Statement, authored by Dr. Balk, states that
deliberate exposure to UV radiation should be avoided due to the associated skin cancer risk and
"[g]uidance should be given about vitamin D adequacy obtained through the diet and
supplements."
78
37.
Salons are not only asserting that customers can obtain vitamin D from tanning
beds, but also claiming that vitamin D from sunlight or tanning beds is superior to vitamin D
from supplementation. For example, Total Tan maintains on its website
79
a link to an article that
claims:
Sunlight exposure is the most reliable way to generate vitamin D in your own
body. In a one-hour sunbath, the body can manufacture up to 10,000 units of
vitamin D. That is more than five times the recently increased recommended daily
allowance for the vitamin. This is another example of how wrong 'health
authorities' can be about vitamins.
It
is impossible for your body to generate too
much vitamin D from sunlight exposure: your body self-regulates and only
produces what it needs.
80
Similarly, Portofino's website claims that "[d]uring a typical tanning session your body naturally
creates as much Vitamin D as you would get from drinking 100 glasses of milk or eating 25
servings of salmon."
81
Portofino asserts that "The benefit of regular UV exposure as the body's
77
79 Fed. Reg. at 31,210,
supra
footnote 55.
Am.
Acad. of Pediatrics Council on Envtl. Health
&
Section on Dermatology, Sophie J. Balk (lead author),
Policy
Statement on Ultraviolet Radiation: A Hazard to Children &Adolescents,
127 Pediatrics 588-97 (2011),
available at
http://pediatrics.aappublications.org/content/l 27 /3/588.full (last visited Jun. 23, 2014).
Total Tan,
Tanning Industry News,
http://www.totaltancorp.com/articles-on-tanning (last visited Jun. 11, 2014).
A print-out of http://www.totaltancorp.com/articles-on-tanning from June 11, 2014 is attached hereto as Exhibit A.
A page from Total Tan's website, reproduced in Exhibit A, states "SUNSHINE ARTICLE 5-1-13" and links to
Vitamin D: The Sunshine Vitamin,
The Gleaner, http://jamaica-gleaner.com/gleaner/20130430/news/news6.html
(Apr. 30, 2013). The article is attached as Exhibit B.
Portofino,
We Make Sunshine,
http://www.portofinosun.com/tanning/we-make-sunshine/ (last visited Jun. 11,
2014). A print-out of http://www.portofinosun.com/tanning/we-make-sunshine/ from June 11, 2014 is attached
hereto as Exhibit C.
81
80
79
78
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only true natural source of sufficient vitamin D production easily outweighs the manageable
risks associated with overexposure to sunlight. "
82
38.
There is no evidence that supports indoor tanning as a "superior" method of
producing vitamin D. Furthermore, there is nothing in the vitamin D obtained from UV
exposure that cannot be obtained through dietary supplementation. In fact, dietary
supplementation of vitamin Dis identical to what is produced by UV exposure-all without the
associated risk of cancer.
83
Thus, because UV exposure from indoor tanning presents health
risks and does not provide superior delivery of vitamin D, vitamin D can be attained more safely
with dietary supplementation. Indeed, the studies that demonstrate beneficial health effects of
vitamin D almost always use oral vitamin D supplements to evaluate the effect of vitamin D.
39.
In fact, there are significant limitations on the effectiveness of vitamin D
production from indoor tanning. UVA and UVB are different wavelengths of UV light. The
body produces vitamin D in response to UVB exposure-not UVA exposure-and the
effectiveness of various indoor tanning devices at promoting vitamin D varies with the amount of
UVB emitted by a sunlamp.
84
Modem tanning beds emit negligible UVB emissions and are
therefore ineffective at stimulating the body to produce vitamin D.
85
Even with older sunlamps
that emit UVB, only a limited amount of vitamin D can be obtained before levels plateau.
86
The
82
Id.
(attributing the statement to Dr. William Grant).
83
Deon Wolpowitz
&
Barbara
A.
Gilchrest,
The Vitamin D Questions: How Much Do You Need
&
How Should You
Get It?,
54
J.
Am. Acad. Dermatology 301-17 (2006).
Robert M. Sayre et al.,
Variability ofPre-Vitamin D3 Effectiveness of UV Appliances for Skin Tanning,
121
J.
Steroid Biochemistry
&
Molecular Biology 331-33 (2010); Autier,
supra
footnote 42.
85
84
Brian Diffey,
Sunbeds, Beauty
&
Melanoma,
157 British J. Dennatology 215-16 (2007); Am. Acad. of Pediatrics,
Ultraviolet Radiation, supra
footnote 40, at 595; World Health Org.,
supra
footnote 4.
Elisabeth Thieden et al.,
Sunbed Radiation Provokes Cutaneous Vitamin D Synthesis in Humans -A Randomized
Controlled Trial,
84
J.
Photochemistry
&
Photobiology 1487-92 (2008); Deon Wolpowitz
&
Barbara A. Gilchrest,
The Vitamin D Questions: How Much Do You Need
&
How Should You Get It?,
54
J.
Am. Acad. Dermatology. 301
(2006); Jody A. Levine et al.,
The Indoor UV Tanning Industry: A Review ofSkin Cancer Risk, Health Benefit
Claims,
&
Regu.lation,
53
J.
Am. Acad. Dermatology 1038-44 (2005).
86
18
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amount of vitamin D synthesized in the body as a result of exposure to indoor UV tanning varies
tremendously, depending on the details of the UV emitted by the particular tanning machine and
the individual being exposed to that UV. For example, while some increases in vitamin D levels
were observed after four, six-minute-long indoor tanning sessions, additional tanning yielded no
significant increase in vitamin D.
87
Thus, modem tanning beds, particularly with repeated use,
will not stimulate the production of vitamin D equivalent to 100 glasses of milk (10,000
international units of vitamin D) as asserted by Portofino.
88
In
any event, this amount would
exceed the upper limit of the recommended daily intake of vitamin D, which may itself be
associated with adverse health effects.
89
40.
Portofino's assertions that the benefits of UV exposure outweigh the risks appear
to rely on one article's critique of the World Health Organization's findings on indoor tanning's
association with cancer: William B. Grant,
Critique of the International Agency for Research on
Cancer's Meta-Analyses of the Association ofSunbed Use With Risk of Cutaneous Malignant
Melanoma,
I Dermato-Endocrinology 294-99 (2009). That article, however, does not represent
generally accepted scientific views or methodologies.
90
His study, funded by the indoor tanning
industry, has many flaws including the exclusion of fair-skinned (Fitzpatrick skin type I)
residents in the United Kingdom from his analysis, which biases and undermines his
conclusions. Grant's conclusions are contradicted by many other studies such as
Exposure to
Indoor Tanning Without Burning and Melanoma Risk by Sunburn History,
authored by Rachel
87
88
Thieden et al.,
supra,
footnote 86.
Exhibit C.
A.
Catharine Ross et al.,
The 2011 Report on Dietary Reference Intakes for Calcium
&
Vitamin D from the
89
Institute ofMedicine: What Clinicians Need to Know,
96 J. Clinical Endocrinology & Metabolism 53 (2011);
see
also
Kaveri Korgavkar, Michael Xiong, & Martin
A.
Weinstock,
Review: Higher Vitamin D Status and
Supplementation May Be Associated With Risks,
European
J.
of Dermatology (2014).
90
See, e.g.,
Weinstock
&
Fisher,
supra
footnote 30.
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Vogel, Rehana Ahmed, Heather Nelson, Marianne Berwick, Martin Weinstock, and DeAnn
Lazovich, in the Journal of the National Cancer Institute (2014). This study reports data from
Minnesota showing that tanning is associated with melanoma risk, even when individuals with
sunburns are excluded.
41.
The vast majority of vitamin D-related health claims made by Total Tan and
Portofino have not been proven and are not generally accepted in the scientific community. The
Vitamin D Council website asserts that vitamin D can treat everything from acne to cancer to
type II diabetes. Although vitamin D is an important nutrient for bone health, studies have not
established a clear link between vitamin D and other health benefits. Particular health claims are
discussed in more detail below.
Indoor Tanning Does Not Prevent or Treat Cancer or Heart Disease
42.
In addition to linking to the Vitamin D Council's information, tanning salons
claim that indoor tanning prevents and treats cancer and heart disease.
91
For example, Total Tan
cites to an article that states:
Contrary to the propaganda, sunlight does not cause cancer.
In
fact, compelling
medical evidence indicates that vitamin D could prevent close to 80 per cent [sic]
of all types of cancer. The research results clearly demonstrate that the lower your
vitamin D levels in your blood, the higher your risk of developing several cancers.
Fifteen cancers have been identified as vitamin D sensitive: colon, stomach,
oesophagus, gallbladder, rectum, small intestine, bladder, kidney, prostate, breast,
endometrium, ovary, Hodgkins and non Hodgkins lymphoma.
92
91
Vitamin D Council,
supra
footnote 76. For example, the Total Tan website (Exhibit A) states "Research from the
Boston University School of Medicine," and links to
Increasing Vitamin D Level Improves Immunity
&
Lowers
Cancer Risk,
Big News Network, http://www.bignewsnetwork.com/index.php/sid/213377328/scat/
ale025da3c02ca7c (Mar. 21, 2013). The article is attached as Exhibit D.
Exhibit B.
92
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Total Tan's website also links to information asserting indoor tanning prevents heart disease.
93
Portofino has similar information, stating "Getting enough vitamin D is linked to reductions in
heart disease, diabetes, multiple sclerosis
&
many cancers-are you getting enough?"
94
43.
While there is some research suggesting a link between chronic (not intermittent)
sunlight
exposure and risk of colon, prostate, and breast cancers as well as non-Hodgkin's
lymphoma, exposure to UV radiation in tanning beds has not been found to be protective.
95
Sunlamps produce intermittent UV exposure for just minutes at a time, and emit a different
mix
of UV radiation
than
the usual solar spectrum.
96
In
short, indoor tanning is not the equivalent of
sunlight exposure and there is no established link between indoor tanning and colon, prostate,
and breast cancers or non-Hodgkin's lymphoma.
44.
Even with respect to sunlight exposure, the data
is
still inconclusive.
Acknowledging the studies that show links between prevention of some cancers and sunlight
exposure, the U.S. Preventive Services Task Force reviewed the literature on the potential
benefits of vitamin D.
97
In its review of 165 primary articles and 11 systematic reviews that
incorporated over 200 additional primary articles, the Task Force noted inconsistent fmdings for
colorectal and prostate cancer, and insufficient studies for pancreatic cancer. The study
For example, the Total Tan (Exhibit A) website states "UK article on sunscreen or as they say suncream," and
links to Lucy Elkins,
Worried Suncream Blocks Vitamin D? Here's Good News ... ,
MailOnline,
http://www.dailymail.co.uklhealth/article-233 5478!Worried-suncream-blocks-vitamin-D-Heres-good-news-
.html#ixzz34NKqrm4y (Jun. 3, 2013) ("Vitamin Dis vital for strong bones and may have many other health
benefits. Studies have linked it to heart health, and it may also have a role in preventing certain cancers."). The
article is attached as Exhibit E.
Portofino, https://www.facebook.com/permalink.php?story_tbid=l Ol 5 l 437886708459&id=l 96996883458
(posted Feb. 28, 2013, last visited Jun. 11, 2014), attached
as
Exhibit F.
95
94
93
Han
van der Rhee et al.,
Is Prevention ofCancer by Sun Exposure More Than Just the Effect of Vitamin D? A
Systematic Review of Epidemiological Studies,
49 European J. Cancer 1422-36 (2013) (addressing only the link
·
between sun exposure and certain cancers, not indoor tanning).
96
97
See, e.g.,
Autier,
supra,
footnote 42.
Mei Chung et al.,
Vitamin
D
With or Without Calcium Supplementation for Prevention of Cancer
&
Fractures: An
Updated Meta-Analysis for the U.S. Preventive Servs. Task Force,
155
Annals
Internal Med. 827 (2011),
available
at
http://www.uspreventiveservicestaskforce.org/uspstfl2/vitamind/vitdart.pdf (last visited Jun. 11, 2014).
21
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examined the effect of both vitamin D and calcium on cancer, and concluded that synthesizing a
dose-response relation between intake of either vitamin D, calcium, or both nutrients and health
outcomes in this heterogeneous body of literature proved challenging.
45.
Similarly, Dr. Clifford Rosen, a member of the vitamin D subcommittee for the
Institute of Medicine, published in The New England Journal of Medicine that "despite the
recent focus in the media on the potential role of vitamin D in reducing the risk of various
chronic diseases, this hypothesis requires testing in large, randomized, controlled trials, and
vitamin D cannot currently be recommended for the purpose of reducing the risk of heart disease
or cancer."
98
46.
With respect to breast cancer specifically, no studies directly support the notion
that sunshine or indoor tanning prevents breast cancer, and the evidence is inconclusive
regarding the role of vitamin Din reducing the risk of breast cancer. Although some studies
have found associations between increased vitamin
D
levels and decreased risk of breast cancer,
a statistically significant inverse association between vitamin D levels and breast cancer remains
unconfirmed.
47.
Perhaps the most aggressively misleading claim on Total Tan's website is its
inclusion
of a
lengthy "testimonial" from
an
individual with kidney cancer "published to keep
you abreast of a current event related to lN light as well as to bring awareness to Kidney
Cancer."
99
Despite Total Tan's statement that "[t]his information is not intended to be used by
any party to make unwarranted health claims to promote sunbed usage," the testimonial explains
the success of a kidney cancer patient who opted to indoor tan at Total Tan in lieu of taking his
98
Clifford J. Rosen,
Vitamin D Insufficiency,
364 New Engl. J. Med. 248, 253 (2011 ).
Total Tan Corp.,
Testimonials,
http://www.totaltancorp.com/testimonials (Last visited Jun. 18, 2013). A copy of
the testimonial as of June 18, 2013 is attached as Exhibit G.
It
appears that this material has since been removed
from the Total Tan website.
99
22