AGENDA ITEM 12
March 22, 2016
Public Hearing
MEMORANDUM
March 18,2016
TO:
FROM:
SUBJECT:
County Council
Amanda Mihill, Legislative
Attorney~
Public Hearing:
Bill 5-16, Tanning Facilities - Amendments
Bill 5-16, Tanning Facilities - Amendments, sponsored by Lead Sponsor Councilmember Hucker,
and Co-Sponsors Council President Nancy Floreen, Councilmembers Leventhal, Katz, Navarro, and
Rice, Council Vice-President Berliner, and Councilmembers Riemer and Eirich was introduced on
March 1, 2016. A Health and Human Services Committee worksession is tentatively scheduled
for April 4 at 9:30 a.m.
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. A memorandum from the Lead Sponsor discussing the purpose
behind Bill 5-16 is attached at <913. Also attached is "The Surgeon General's Call to Action to
Prevent Skin Cancer" which lists in one of its goals to "reduce harms from indoor tanning"
(<915-20).
This packet contains:
Circle
#
1
Bil15-16
12
Legislative Request Report
13
Sponsor memorandum
15
The Surgeon General's call to Action to Prevent Skin Cancer
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Bill No.
5-16
Concerning: Tanning
Facilities
Amendments
Draft No.
~
Revised:
3n/2016
Introduced:
March 1. 2016
Expires:
September 1. 2017
Enacted: _ _ _ _ _ _ _ __
Executive: _ _ _ _ _ _ _ __
Effective: _ _ _ _ _ _ _ __
Sunset Date: ....:...:,No=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 EIrich
AN
ACT to:
(1)
(2)
(3)
(4)
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.
By amending and renumbering
Montgomery County Code
Chapter 51A, Tanning Facilities
Sections 51A-l, 51A-2, 51A-3, 51A-4, 51A-5, 51A-6, 51A-7, 51A-8, 51A-9, 51A-1O,
51A-ll, 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 unaffected 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-l, 51A-2, 51A-3, 51A-4, 51A-5, 51A-6, 51A-7, 51A-8, 51A-9, 51A-IO,
51A-ll, 51A-12, 51A-13, 51A-14, and 51A-15:
51A-l. 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)]
Tanningdevice[:
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 equipment that emits
electromagnetic radiation having wavelengths in the air between
200 and 400 nanometers and that is used for tanning of human
skin.
Tanning device
includes any accompanying equipment,
including protective eyewear, timers, and handrails.
2
3
4
5
6
7
8
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15
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21
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24
[51A-2. Scope.]
[This chapter does not apply to a licensed health care professional who uses a
tanning device.]
[51A-4] 51A-2. License required.
(a)
[It is unlawful for any person to] A person must not operate a tanning
facility without a valid license issued by the [department] Department
under this [chapter] Chapter.
I'~
25
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27
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BILL
No. 5-16
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(b)
A license authorizes a person to operate a tanning facility only at the
location identified in the license.
(c)
A license issued under this [chapter] Chapter is not transferable.
However, a new owner may continue to operate a tanning facility under
the tenns ofthe 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.
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34
35
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37
38
39
[51A-5] 51A-3. Application for license.
(a)
In general.
A person who wants to operate a tanning facility must:
(1)
[Submit] submit an application to the [department] Department
on the form that the [department] Department requires; and
(2)
[pay]
P.ID::
to the [department] Department a license fee in the
amount that the [county executive] County Executive determines
by regulation adopted under [method] Method (3).
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(b)
Contents ofform.
The application must include:
(1)
(2)
[The] the name and address ofthe applicant;
[The] the location and telephone number of the tanning facility
for which the application is made;
(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.
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51
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53
(c)
New equipment.
A person who operates a tanning facility must notify
the [department] Department of the name, description, and year of
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BILL
No. 5-16
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manufacture of any new equipment it uses within [thirty (30)] 30 days
after installing the new equipment for use.
[51A-6] 51A-4. Issuance of license; inspection.
(a)
Issuance.
The [department] Department must issue a license to any
person who:
(1)
[Submits] submits an application under [section SIA-S] Section
[[SIA-4]] SIA-3;
(2)
[pays]
Pill
the license fee required under [section SIA-S]
Section [[SIA-4]] SIA-3; and
(3)
(b)
[Meets] meets all other requirements ofthis [chapter] Chapter.
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[(
c)]
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.
[51A-7. License.]
[(a)]
(£)
Contents Q[license.
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
reqUlres.
[(b)]
@
Term Q[license.
A license is valid for [one
(1)]
Issuance.
1
year after its date of
W
Display.
A licensee must display the license conspicuously in the
tanning facility.
[51A-8. Renewal] 51A-5. License renewal.
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BILL No.
5-16
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(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
reqUires;
(2)
[pays]
mY§
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85
.
a renewal fee equal to the license fee established
86
87
under [section 51A-5] Section [[51A-4]] 51A-3; and
(3)
(b)
[Meets] meets all other requirements of this [chapter] Chapter.
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Extension.
An existing license continues in effect until the [department]
Department acts on the renewal application if:
(1)
(2)
(c)
[The] the licensee meets the requirements of subsection (a); and
[The] the existing license has not been suspended or revoked.
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93
94
95
96
97
98
99
Term.
A license is valid for [one (1)]
1
year after its date of renewal.
[51A-ll] 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.
[51A-13] 51A-7. [Use requirements] Duties; prohibition of use
~
minors.
(a)
Tanning/aGility.
A tanning facility must:
(1)
[Have] have a trained attendant on duty whenever the facility is
open for business;
100
101
102
(2)
[a.] (A) [provide] provide each customer with protective eyewear
that meets the standards for tanning devices established
under this [chapter] Chapter; and
[b.]
@
[Not allow] prohibit a person [to use] from using a
tanning device if that person does not use the protective
eyewear.
103
104
105
106
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Bill
No. 5-16
107
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109
(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;
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111
(4)
[Limit] limit each customer to the maximum exposure time as
recommended by the manufacturer;
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113
114
115
116
117
(5)
ensure that
~
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;
®
[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
123
124
125
ill
tID
(2)
ensure that each tanning device is equipped with
~
mechanism
that allows
~
customer to
turn
the tanning device off;
prohibit
~
customer from using
~
tanning device in the facility
more than once every 24 hours;
sanitize each tanning device after each use;
provide
~
am
(b)
written warning as required in Section [[SIA-9]]
5IA-8; and
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127
128
129
130
131
132
Ql)
maintain records as required in Section [[SIA-IO]]
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:
[a.]
CA)
[Has] has read and understood the warnings before using
the device; and
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Bill No. 5-16
133
[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.]
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139
!Jl
(a)
A person under the age of 18 must not use
!!
tanning device.
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151
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153
[51A-12] 51A-8. Warnings.
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 burns;
[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:
[a.
[b.
[c.
[d.
[e.
[f.
[g.
(5)
Foods] (A) foods;
Cosmetics]
ill)
cosmetics;
Tranquilizers]
(Q}
tranquilizers;
Diuretics]
@
diuretics;
Antibiotics]
(ID
antibiotics;
High]
(E)
high blood pressure medicines; and
Birth] (Q) birth control pills; and
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Any person taking a prescription or over-the-counter drug should
consult a physician before using a
tanning
device[.]~
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BILL
No. 5-16
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(
e)
®
(b)
i1
is
~
violation
of County Code §51A-8 for
~
person under the
age of 18 to use
f!
tanning device.
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
~
must state that
it is
~
violation of County Code §51A-13 for
~
person under the age of
.lli
to use
~
tanning device.
(d)
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.
[51A-14]
51A-9.
Injury
report; records.
(
a)
Injury report.
(1)
Tanning/aeility.
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
[b.]
tID
[Send] send a copy ofthe injury report to the person who
is injured or complains of an injury.
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BILL
No. 5-16
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(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.
[51A-9] 51A-IO. 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 ofthis [chapter] Chapter.
[51A-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 ofhealth care professional.
[51A-IO] 51A-12. Enforcement.
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202
203
204
(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.
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206
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208
(b)
Denial, suspension, revocation.
The [department] Director may deny,
suspend, or revoke a license under this [chapter] Chapter if the
[director] Director finds, after a hearing for which written notice has
been given, that an applicant or licensee has:
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No. 5-16
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(1)
[Made] made a material false statement on an application for an
initial or renewal license;
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(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
fmds 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.]
(ID
[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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(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
and must reinstate the license if the tanning facility conforms to the
provisions ofthis [chapter] Chapter.
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BILL
No. 5-16
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(e)
Notice.
Notice to an applicant or licensee under this [section] Section is
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
ill
(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
Bil15-16
Tanning Facilities
-
Amendments
DESCRIPTION:
PROBLEM:
Bill 5-16 would generally update County law related to tanning
facilities and prohlbit 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 hlgher 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
WITIDN
MUNICIPALITIES:
PENALTIES:
To protect public health by updating the general laws related to tanning
facilities and prohlbit minors from using tanning facilities.
Department of Health and Human Services
To be requested.
To be requested.
To be requested.
To be researched.
Amanda Mihlll, 240-777-7815
Not applicable.
Class A violation.
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MONTGOMERY COUNTY COUNCIL
ROCKVILLE, MARYLAND
TO: Councilmembers
FROM: Councilmember Tom Hucker
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 27.9%.
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 harmful 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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311712016
The Surgeon General's Call
to
Action
to
Prevent Skin Cancer
I
SurgeonGeneral.gov
The Surgeon General's Call to Action to Prevent Skin Cancer
Executive Summary
The Surgeon General sCali
tc
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..l::l Skin cancer greatly affects quality of life, and it can be
disfiguring or even deadly.l.H 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 $8.1 billion.!! Melanoma is
responsible for the most deaths of all skin cancers, with nearly 9,000 people dying from it each year.
lJl
It
is
also one ofthe most common types of cancer among U.S.
adolescents and young adults.ll 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.lJ1::l.2 With adequate support and a unified approach, comprehensive, communitywide efforts to
prevent skin cancer can work. 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,lZ::ll the most common types of skin cancer
are also strongly associated with exposure to UV
radiation.~
As many as 90% of melanomas are estimated to be caused by UV
exposure.~
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
,[N
exposures (such as prolonged sun exposore without adequate sun protection) and intentional exposure for the purpose of skin tanning (whether
indoors using an artificial UV device or outdoors wbile 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.J.J..J.2. 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.llJ! This damage can lead to cancer. The degree to which LN exposure increases a person
'&
risk of skin cancer depends on
many factors, such as individual skin type, the amount and types ofsun protection used, whether exposure is constant or intermittent, and the age at which the
exposure
occurs.ll,lll.~
By reducing intentional UV exposure and increasing sun protection, many
skin
cancer cases can be prevented.
l
.M::2.2
,
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 ofUV 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.2!i 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 ofthe accumulation of exposure over time from more years
oftanning.~
The relationship between outdoor UV exposure, vitamin D, and human health is complex. The amount ofoutdoor 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.~.!Z
Although all UV exposures can affect skin cancer risk, entirely avoiding UV rays
from the sun is neither realistic nor advisable for most Americans. Spending time outdoors is associated with positive health benefits, such as increased levels of
physical activity and improved mental health.
48-50
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..sJ..ll In addition, indoor tanning rates are high among some
1/R
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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 hanns of indoor tanoing.
Individuals can take steps to reduce their risk ofdeveloping 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.~ji
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 ofpeak sunlight (such as midday). and using sunscreen (in conjunction with other sun protection
behaviors).~
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 prcference
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 tife, and building healthy habits early when children are more receptive can lead to increased sun
protection into adulthood.fi.8..!i2 Given the amount oftime children spend in school settings, much ofthe 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 Guidell) states that sufficient evidence exists to recommend multicomponent, communitywide
interventions,!!. 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).1ll
Intervention strategies that address social and contextual factors have the potential for broad public health impact hy making the healthy choice the easy or default
choice.ll Policies, legislation, and regulation are examples of such interventions, reaching wide segments ofcommunities while requiring minimal individual effort
compared with interventions directed at individuals.ll
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.1.Ul California law also urges employers to identify and
correct workplace hazards counected to UV radiation.
N
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.1Uli. Kentucky passed a law encouraging skin cancer education in
schools. ll 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.1S.
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 20
II,
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.1!1. 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.1.2::.U
Currently, at least 44 states and the District ofColumbia 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 otherwise reduce harms (such as
requiring eye
protection).~
Indoor tanning laws, particularly those that include age restrictioos_ appear to be effective in reducing indoor tanning among female
high school students, who have the highest rates.M.
Federal policies, legislation, and regulations can help prevent skin cancer.
The
U.S. Department ofHealth and HUIIllIti 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 ofHealth, 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
approval.ll1 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 IS 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, hats, and sunglasses. ll1
FDA also regulates indoor UV tanning devices under separate authorities, both as medical devices and as radiation-ernitting electronic products. On May 29, 2014,
FDA reclassified indoor tanning devices to Class II medical devices (moderate to high risk).!U2 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 51
O(k)
clearance from FDA for newly
marketed devices, and meet other requirements.2Q
The Surgeon General
So
Call
to Action to Prevent Skin Cancer
is informed by international efforts to prevent skin cancer. Other countries have taken a variety of
approaches to prevent skin cancer, including community-based, multicomponent interventions, which are recommended by The Community Guide.1.Q.2l 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.~
Many countries have laws specifically addressing indoor tanning. Brazil and New South Wales, Australia, have passed complete hans on indoor tanning.
93 .94
In
addition, as ofJanuary 2014, France, Spain, Portugal, Germany, Austria, Belgium, the United Kingdom, Australia, Iceland, Italy, Finland, and Norway prohibit indoor
tanning for youth younger than age 18
years.ll~
@
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SurgeonGeneral.rpI
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 sunburn despite improvements in sun protection and ongoing
high rates of indoor tanning despite evidence that it is a human carcinogen. More information 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.
l l
This section also provides
education and communication strategies, which will likely be most effective ifused 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.
Goall: 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 workers.
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 offederal 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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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.
communitywide interventions are defined as interventious 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
b
Multicomponent,
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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