1. Indoor Tanning Operator Compliance & Knowledge Robin L. Hornung, MD, MPH Pediatric Dermatologist, The Everett Clinic Clinical Associate Professor UW Division of Dermatology

2. Overview Present research in areas of: –Indoor tanning compliance with safety regulations –Tanning operator knowledge and training –Laws that restrict youth access

3. Indoor Tanning Compliance In 1991 an inspection of 32 NC tanning facilities found only 1 in complete compliance with the 21 state and federal safety regulations > 7 infractions/facility (0-21) 19% had timers not within required +/- 10% accuracy level Fleischer AB et al, J Am Acad Derm 1993;28:212

4. Indoor Tanning Compliance 50 NC tanning facilities evaluated during state inspections: –Were patrons complying with the FDA recommended “safe” exposure schedules outlined on the tanning beds ? –Established guidelines are based on getting no more than 0.75 minimal erythemal dose (MED) 3 times the first week, gradually increasing the exposure thereafter Hornung RL et al, J Am Acad Derm 2003;49:655

5. Indoor Tanning Compliance 95% of patrons were not following the safe exposure guidelines ~ 1/3 rd actually started at the maximum levels (>4 MED) Average length of tanning on the first visit was > 14 minutes Primary tanning facilities where the sole business was for tanning, the patrons had significantly shorter tanning times Hornung RL et al, J Am Acad Derm 2003;49:655

6. Indoor Tanning Compliance We also studied the amount of UV radiation emitted by tanning beds –The tanning beds emitted 4x more UVA and 2x more UVB when compared to radiation emitted by the noon-day sun in Washington D.C –In high-pressure sunlamps radiation can reach doses 10-15x that of the sun Hornung RL et al, J Am Acad Derm 2003;49:655 Gerber B et al, Photochem Photobiol 2002;76:664

7. Indoor Tanning Compliance In San Diego a study utilized phone interviews to assess compliance with recommended exposure schedules: –Compliance was measured as the weekly frequency of visits – Only 6.8% in compliance with the FDA recommended exposure guidelines Kwon HT et al, J Am Acad Derm 2002;46:700

8. Knowledge & Training Among Indoor Tanning Operators Survey of tanning operators in Michigan: 63% did not believe that tanning beds can cause cancer Survey of tanning operators in New York: 80% said one could not get skin cancer from artificial tanning, 75% said one could not get a sunburn from artificial tanning Beyth R et al, J Am Acad Dermatol 1991;24:277 Fairchild AL et al, Am J Prev Med 1992;8:381

9. Knowledge & Training Among Indoor Tanning Operators Survey of 1008 high school students in Minnesota: –50% said they were not warned about potential dangers –28% reported not being told to wear goggles –17% reported never using goggles Oliphant JA et al, Am J Public health 1994;84:476

10. Knowledge & Training Among Indoor Tanning Operators 400 facilities in 4 states, 87% of operators advised patrons of the potential risk of sunburn < 50% facility operators in Colorado, Texas and Wisconsin informed patrons about the risk of skin cancer vs 81% in Illinois Heilig LF, et al, Cancer Causes Control 2005;16:557

11. Knowledge & Training Among Indoor Tanning Operators FDA has databases in which medical device associated injuries are reported –142 records were compiled from these databases from 1985-2006 –Of the reported injuries ~50% resulted from UV exposure –36% of the UV-related injuries were attributable to (user/operator) noncompliance with FDA sunlamp guidance policies Dowdy JC et al,Photodermatol Photoimmunol Photomed 2009;25:216

12. Knowledge & Training Among Indoor Tanning Operators In a large Burn and Plastic Surgery practice in the UK they have noticed a rise in the number of patients presenting with burns related to sunbed use over the last several years Hemington-Gorse SJ et al, Burns 2010 Feb 17 [Epub ahead of print]

13. Knowledge & Training Among Indoor Tanning Operators Survey of tanning operators in North Carolina: –71% never got any formal training –only ~ 1/3 of tanning device operators were aware of common photosensitizing drugs –some (3%) even allowed children under age 10 to tan Fleischer AB et al, J Am Acad Dermatol 1992;27:199

14. Knowledge & Training Among Indoor Tanning Operators In Washington state, 70% of the parents surveyed said they never wanted their children to use tanning devices We found children as young as 5 years old were currently using tanning beds On average children were using them 4 years younger than their parents Magee KH et al, Pediatr Dermatol 2007;24:216

15. Conclusion Extreme variability in –tanning devices and their radiation output (which is typically extremely high) –operator knowledge and training (which is often very limited) –compliance with state and federal guidelines (which is often very poor) Many states have no regulations whatsoever

16. Conclusion In states where there are laws restricting youth access, a recent (and the largest) study found the laws: –Improved rates of parental consent –Improved rates of parental accompaniment –Reduced access to minors where this was prohibited –The laws were not very helpful in preventing every day usage Pichon LC, et al, Arch Dermatol 2009;145:997