The battle over indoor tanning heats up: Despite some recent gains, reducing the risk of a known carcinogen will require far more than good science.

Abstract

Meghan Rothschild had been using tanning beds every week for approximately 2.5 years when she noticed an increasingly dark and itchy mole on her stomach. In 2004, after the 19-year-old college student insisted on having the mole removed, she was diagnosed with stage II melanoma. Now the marketing and public relations manager for IMPACT Melanoma, a nonprofit based in Concord, Massachusetts, that focuses on reducing the cancer's incidence, Ms. Rothschild recalls that the diagnosis required her to have a much larger margin of skin excised, multiple lymph nodes removed, and drainage tubes inserted. Luckily, her melanoma had not spread. The 34-yearold cancer survivor has widely shared her ordeal to help others avoid becoming casualties of a disease whose known risk factors include exposure to ultraviolet (UV) rays, whether from the sun or indoor tanning beds. A 2012 meta-analysis concluded that individuals who first use a tanning bed before age 35 years, like Ms. Rothschild did, increase their risk of melanoma by approximately 59%.1 “I think eventually tanning beds will be the cigarettes of my generation,” Ms. Rothschild says. However, as researchers and advocates are discovering, translating scientific conclusions and public health messaging into fewer melanoma cases will be no easy feat. “It's more difficult than I think it should be, or at least I would like it to be, because the science is very, very clear,” says Rebecca Chibnall, MD, assistant professor of dermatology at Washington University in St. Louis, Missouri. Although melanoma has been firmly linked to UV radiation as well as other environmental and genetic risk factors, its etiology is less certain. Researchers likewise have struggled to separate causation from correlation when attempting to explain recent trends in melanoma incidence. More broadly, advocates still are trying to decouple what they say is the widely reinforced but dangerous link between looking tan and looking healthy. “There's nothing about tanned skin that's healthy. It's a defense mechanism by your body to fight against radiation,” says Sherry Pagoto, PhD, a clinical psychologist and director of the University of Connecticut's Center for mHealth and Social Media in Storrs, Connecticut. From a policy standpoint, the anti-tanning bed movement has been buoyed by several key victories. The US Department of Health and Human Services and the International Agency for Research on Cancer, part of the World Health Organization, both have classified UV exposure as “carcinogenic to humans,” putting it in the same category as tobacco, alcohol, benzene, asbestos, and other chemicals. In 2010, the federal Patient Protection and Affordable Care Act imposed a 10% tax on tanning beds, in part to generate revenue and in part to curb their use. Although repeatedly targeted by opponents such as the American Suntanning Association, the tax has stayed in place. At the state level, researchers like Dr. Chibnall and Dr. Pagoto say they have been encouraged by the bipartisan momentum toward stricter laws despite the tanning industry's opposition. So far, 16 states and Washington, DC, have banned all minors from indoor tanning, while another 12 states have restricted the access of some children, according to a running tally by the National Conference of State Legislatures. Dr. Chibnall has spoken in favor of a bill banning indoor tanning by minors in Missouri, where youth tanning rates are nearly double the national average. Some public health officials have credited the tax and bans with helping to drive down demand among high school students, one of the groups at highest risk of melanoma. A 2017 study by researchers at the US Centers for Disease Control and Prevention reported that the percentage of high school students who said they used tanning beds dropped by greater than one-half from 2009 to 2015, from 15.6% to 7.3%.2 Since she began publicly sharing her story about 12 years ago, Ms. Rothschild says she has noticed a similar shift in attitudes: fewer young people say they are using tanning beds and more say they understand the risk. A more recent study from the Centers for Disease Control and Prevention offered mixed news about melanoma: between 2005 and 2014, incidence rates dropped among adults aged younger than 45 years, particularly among those aged 15 to 24 years, but continued to climb among older adults.3 Myles Cockburn, PhD, professor of epidemiology at the University of Colorado Cancer Center in Denver, says the rising rates in adults with years of cumulative UV exposure is easier to explain. “We know that even one really bad sunburn can double your risk of melanoma later in life,” he says. For many baby boomers who tanned for years, the damage already is done. What about the dip in incidence among younger adults? Some dermatologists and advocates have suggested that the decrease in tanning bed use by minors might be partly responsible. However, at least so far, Dr. Cockburn says there is no good evidence to suggest that prevention efforts can be credited with the success. Instead, he hypothesizes that reduced sun exposure and thus melanoma risk could be an unexpected byproduct of the nation's obesity epidemic, fueled by the increasingly sedentary and indoor lifestyles of children and young adults. Nevertheless, Dr. Cockburn emphasizes that decades of research back the ongoing efforts to lower melanoma risk by reducing UV exposure, and he strongly supports the drive to restrict minors' use of tanning beds. “It's astonishing that it wasn't done earlier,” he says. Countering the danger of UV exposure in adults may be more dependent on social messaging, but health agencies and researchers still are learning which groups are at higher risk and why. In a recent study, Dr. Pagoto found that although fewer men use tanning beds overall, those who do tend to have riskier habits.4 “They did it more often and tended to like settings where there weren't as many regulations, which is concerning,” she says. “There's nothing about tanned skin that's healthy. It's a defense mechanism by your body to fight against radiation.” —Sherry Pagoto, PhD A separate study found that gay and bisexual men, who have higher than average rates of skin cancer, were more than twice as likely as heterosexual men to report having ever used an indoor tanning service, putting them on par with the reported use by young women.5 “Men aren't immune to that: wanting to look a certain way,” Dr. Pagoto says. Ironically, some of the same colleges with dermatology departments sounding the alarm also offer tanning beds in their on-campus housing. So do many off-campus apartment complexes competing for younger tenants in college towns. Even 2 of the largest international health club chains, Anytime Fitness and Planet Fitness, offer tanning beds as member benefits. McCall Gosselin, vice president of public relations and communications for Planet Fitness, told CytoSource in an e-mailed statement that the chain's locations are required to adhere to local and national laws. “In fact, we often impose stricter regulations than are required,” Ms. Gosselin said, although she did not specify what those regulations entail. Mark Daly, a spokesman for Anytime Fitness, said in response to concerns about health risks that “significantly fewer” of the chain's recently opened franchises have equipped their gyms with a tanning bed compared with older franchises. He also stressed that “the small percentage of members who use the tanning beds typically do so once or twice a year, prior to vacationing in a sun-splashed locale—to prevent sunburn.” In fact, Dr. Chibnall says, the widespread notion of a “protective” base tan is a myth. “Any tan is just a manifestation of damage to the skin,” she says. Ultimately, the science can only go so far. The biggest gains in risk reduction, advocates say, may require a wholesale change in public attitudes concerning which skin tones look “healthy” or “beautiful.” To change public perceptions, IMPACT Melanoma has joined forces with the National Council on Skin Cancer Prevention on an educational project called the Skin Smart Campus initiative. Beyond encouraging colleges and universities to stop promoting tanning beds, the initiative offers a free online curriculum called “Your Skin Is In” that is aimed at middle school, high school, and college students. “They learn about safe sex, and not to drink alcohol, and not to smoke cigarettes,” Ms. Rothschild says. In the same conversation, she says, it is time to talk about tanning beds too.