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Unlimited and Unrestricted access to Unlimited and Unrestricted access to ultraviolet radiation: A case for effective ultraviolet radiation: A case for effective state regulation over the indoor tanning state regulation over the indoor tanning
industryindustry
Meghana Desai Aruru, PhD (Candidate), MBA, B.S.PharmJ.Warren Salmon, PhD
Dept. Of Pharmacy AdministrationUniversity of Illinois at Chicago
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AgendaAgenda
• Introduction• Tanning practices• Epidemiology of UV radiation on skin• Fitzpatrick skin type classification• Indoor Tanning Industry• Policies pertaining to indoor tanning• Discussion & Questions
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IntroductionIntroduction
• UV tanning – outdoors (sun) & indoors (tanning units)Prevalence of indoor tanning is defined variously as any use in the past 6 or 12 months or frequent use in the past 12 months
• NCI – Skin cancer most common form of cancer in U.S, diagnosed in more than 1.5 million Americans each year
• Increasing incidence of melanoma and non-melanoma skin cancers2005 : 59,580 melanoma cases, 7,770 deaths2006 : 62,190 melanoma cases, 7,910 deaths (estimated)
• SEER statistics - an average of 18.8 life-years lost per melanoma death. Melanomas addressed in Healthy People 2010, growing concern in AMA, WHO, AAD
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UV Radiation UV Radiation
200 nm 280nm 320nm 400nm UVC UVB UVA
(absorbed by ozone) (highly carcinogenic) (weakly carcinogenic)
Acute & Chronic effects from UV radiation
Short term – itching, nausea, pruritis, xerosisLong term - polymorphous light eruption, disseminated
superficial actinic porokeratosis, mid-dermal electrolysis and actinic granulomas, melanomas, basal and squamous cell carcinomas
Pre-existing photosensitivity in Lupus Erythmatosus, Polymorphous Light Eruption, Porphyria, and Rosacea significantly exacerbated by exposure to indoor tanning
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Emergence of tanningEmergence of tanning
1930’s & 40’s – Medical profession encouraged sun exposure as benefit to children
1948 – First reported studies of vitiligo with oral & topical psoralen
Development of ‘tan’ for cosmetic purposes – French designer Coco Chanel
1970’s – Development of UVA beds for medicinal purposes
Commercialization soon after with formation of the Indoor Tanning Association
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Skin cancersSkin cancers
Melanoma in U.S –
Incidence rates rising by 4-8% each year Lifetime incidence is 1/71 3% of all cancers 1% of all cancer deaths Most common cause of death in women 30-39
years
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Skin Cancers - MelanomasSkin Cancers - Melanomas
Melanoma in the U.S
0
10000
20000
30000
40000
50000
60000
70000
2000 2001 2002 2003 2004 2005 2006
Year
New
cas
es
7000
7200
7400
7600
7800
8000
Dea
ths
New cases Melanoma Deaths
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Skin cancers - MelanomasSkin cancers - Melanomas
Risk factors:
Family history Red/Blond hair Ample UV exposure (freckling on upper back, history of 3
or more sunburns before age 20, 3 or more outdoor jobs before age 20)
Actinic keratosis Skin types I & II Advanced age Atypical or congenital nevi
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Skin typesSkin types
Fitzpatrick’s classification – 1977
SED = sub erythemal dose
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Skin type assessmentSkin type assessment
• Sun sensitivity or skin type remains constant during a lifetime
• Self assessment by individual tanners
• Assessment by low-wage, insufficiently trained tanning salon operators
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Indoor Tanning AssociationIndoor Tanning Association
Total Number of Professional Indoor Tanning Facility Businesses: 25,000
Total Number of Professional Tanning Business Employees: 160,000
Total Professional Indoor Tanning Facility Customer Base: 30 million
Total Revenues Professional Indoor Tanning Facilities: $5 billion
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Indoor Tanning IndustryIndoor Tanning Industry
Misleading advertisements &/or falsified messages:
Promoting UV protection through indoor tanning (lack of sufficient epidemiological evidence)
Promotion of health benefits through Vitamin D production
Promotion of trade-offs of certain internal cancers
Stand against sunscreens
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Indoor Tanning IndustryIndoor Tanning Industry
Significant advertising & promotion to students
Formed a Political Action Committee (PAC) to prevent ban on under-18 tanning
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Indoor Tanning IndustryIndoor Tanning Industry
Tanning salon operator education:
Through 2 private institutions – National tanning Training Institute (NTTI) and International Smart Tan Network (ISTN).
No training for skin typing
No training for radiation related burns and/or emergency procedures
No demonstration of equipment handling
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Indoor TanningIndoor Tanning
Source: www.cartoonstock.com
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Tanning Salon OperatorsTanning Salon Operators
Source: www.cartoonstock.com
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Regulation & LegislationRegulation & Legislation
FDA – regulates equipment, adherence to performance standards, warning signs (FDA, 21 CFR Ch.1 § 1040.20)
Regulation since 1979 – Federal standards adopted to protect customers from eye and skin injuries
1985 – Amendments by allowing longer exposure times for UVA emitting lamps
1986 – Policy letter published on recommended exposure schedules
Currently – no regulation or monitoring of exposure times of patrons, no requirements for maintaining much information
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Regulation & LegislationRegulation & Legislation
FTC – prohibits deceptive advertising
Individual states governance
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ScreeningScreening
Differences of opinions:
AAD, ACPM – regular screeningIOM, NCI – insufficient evidence for screeningUSPSTF, CTF – screening at-risk population
Early detection of melanomas: High 5-year survival rate
External & visible cancer with known risk factors
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DiscussionDiscussion
According to Sharon A. Miller at the FDA’s Center for Devices and radiological Health:
“FDA does not recommend the use of indoor tanning equipment”
Comments: - FDA does not regulate prevalence of indoor tanning - Currently no legislation protecting minors explicitly - No safeguards in place to protect the general tanning
population - No requirements for exposure schedules or monitoring
of UV radiation sessions in tanning salons
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DiscussionDiscussion
Significant efforts by AAD, WHO, AMA to ban under-18 tanning
Involving health professionals to detect melanomas and other skin cancers
Regulation over exposure schedules with mandated record keeping
Risk communication to adolescents – immediate perceived benefits versus long term health issues
Development of melanomas at later ages – Medicare burden
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ConclusionConclusion
UV exposure presents a significant and serious public health problem
State health departments should mandate cancer risk reduction
Need enforceable state regulatory safeguards in place
Consumer awareness alone does not change tanning behaviors
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ConclusionConclusion
Under-18 adolescents typically do not understand risk-benefit tradeoffs
Concern about additive effects from both indoor & outdoor tanning from studies
Concern about proposed tanning addictions
Need for also stepping up oversight by FDA & FTC
All suggestions are reasonable and not overly burdensome
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ConclusionConclusion
Increasing vigilance by state health departments over indoor tanning activities including monetary penalties
Monitoring tanning salon operator training to include in depth understanding of skin cancers in relation to UV radiation
Public Health commitment required for best course of action
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