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Analysis of Indoor Tanning Legislation in the United States

Analysis of Indoor Tanning Legislation in the United States

Dr. David Buller, Klein Buendel Director of Research, and a national team of scientists, physicians, and attorneys, have published an article in the American Journal of Public Health that describes the progression, content, and stringency of state legislation regulating indoor tanning in the United States.

Skin cancer is a highly prevalent, potentially deadly, and expensive disease. Indoor tanning is a well-established cause of melanoma and keratinocyte (non-melanoma) carcinomas. In the most recent estimates, nearly 6% of adolescents and 5% of adults indoor tan. Most individuals begin indoor tanning as adolescents or young adults. Stringent state indoor tanning laws that include age bans for minors instead of just parental consent are associated with less indoor tanning.

For this study, trained research assistants used legal mapping methods to collect and code legislative bills on indoor tanning introduced in U.S. states, the District of Columbia, and Puerto Rico. The research aimed to (1) describe the progression of state indoor tanning legislation (enacted or failed); (2) detail the content and stringency of bills with special attention to whether bills banned indoor tanning by minors (individuals aged younger than 18 years (under-18 ban); and (3) explore the potential impact of political party affiliation of state government leadership when bills were proposed.

Between 1992 and 2023, 184 bills were introduced in 49 of 50 states and the District of Columbia (56 laws were enacted, and 126 bills failed). An under-18 ban was enacted in 22 states and the District of Columbia. Analyses calculated composite scores on the stringency of age restrictions and of warnings, operator requirements, and enforcement. The research team evaluated associations of the political party of the legislative sponsor and legislature majority. Specific methods, coding protocols, statistical analyses, results, conclusions, limitations, and public health implications are detailed in the American Journal of Public Health paper.

In many states, it took several years and proposed bills before a law on indoor tanning was enacted. Enacted bills were more stringent than failed bills. Party affiliation of the bill sponsor and legislature majority combined to affect bill passage and age restrictions. Increasing support for stringent regulations on indoor tanning is evident and may motivate other states or the federal government to prohibit minors from using indoor tanning facilities in an effort to improve health and prevent death.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Paper authors include Dr. Carolyn Heckman, Ms. Anna Mitarotondo, and Mr. Kevin Schroth from Rutgers University; Mr. Alan Geller from Harvard University; Dr. Jerod Stapleton from the University of Kentucky; Ms. Samantha Guild from the AIM at Melanoma Foundation in Texas; Dr. Jeffrey Gershenwald from the MD Andersen Cancer Center at the University of Texas; Dr. Robert Dellavalle from the University of Minnesota; Dr. Sherry Pagoto from the University of Connecticut; and Dr. David Buller, Ms. Julia Berteletti and Ms. Irene Adjei from Klein Buendel.

Indoor Tanning Policies Are Insufficient to Protect Young Adults

Indoor Tanning Policies Are Insufficient to Protect Young Adults

Ms. Anna Mitarotondo, a Research Program Manager from Rutgers University, gave a Research Spotlight presentation on the Indoor Tanning Policy research project at the 45th Annual Sessions and Meeting of the Society of Behavioral Medicine in Philadelphia, PA, March 13-16, 2024. Dr. Carolyn Heckman from Rutgers and Dr. David Buller from Klein Buendel are the project’s Multiple Principal Investigators.

Ms. Anna Mitarotondo, Rutgers University

Five million Americans are treated for skin cancer annually with the incidence of melanoma tripling in the last 40 years. Even a single session of indoor tanning is a well-established cause of melanoma especially at younger ages. Indoor tanning is also associated with sunburn, another major risk factor. In addition to FDA safety regulations, 46 states restrict minor indoor tanning access. More stringent laws (such as age bans vs. parental consent or no law) have been associated with less youth indoor tanning. However, enforcement and compliance are essential for successful law implementation. This study investigates regulation stringency, behavior, facility compliance, and sunburns.

The research team conducted an online, nationally representative survey of 1000 individuals aged 18-29 who indoor tanned in the last three years. 82% identified as female, and 74% as white, non-Hispanic. A majority (89%)  indoor tanned multiple times in the past three years. Participants reported being most likely to tan in indoor tanning salons, gyms, and beauty salons. They also reported indoor tanning in homes, spas, and apartment complexes, with participants indoor tanning in more types of facilities after age 18. Despite FDA recommendations, participants reported that only 16% of facilities prohibited daily or unlimited tanning. Nearly half (48%) of participants were not informed of time limits when indoor tanning. Half (50%) reported that over half of the time, they were able to avoid indoor tanning facility rules. Nearly two-thirds (61%) of participants reported burning from an indoor tanning device in the past three years, with 15% reporting a burn from their most recent session. Of participants who reported indoor tanning as minors, 61% reported burns and 30% reported getting medical attention.

This is the first study to show rates of indoor tanning at facilities other than tanning salons, both before and after age 18, in a representative national sample. Participants reported insufficient facility compliance with, and enforcement of, indoor tanning regulations, which in some cases may have led to severe burns. Analyses are underway to further investigate regulation stringency, enforcement, and compliance by type of facility and state, adjusting for demographic factors and additional key covariates. The goal is to inform future indoor tanning policies at the state and federal level.

This research was supported by a grant to Rutgers from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Coauthors included and Ms. Maame Araba Assan from Rutgers University, Dr. Jerod Stapleton from the University of Kentucky, and Ms. Julia Berteletti from Klein Buendel.

Stringency of State Indoor Tanning Laws

Stringency of State Indoor Tanning Laws

Approximately five million cases of skin cancer are diagnosed among Americans at a cost nearing $9 billion annually. Indoor tanning (IT) is a risk factor for skin cancer. Restricting IT facilities, especially access by minors, has been the subject of state laws. More stringent restrictions on youth access (for example, bans by age vs. parental consent laws) appear to be associated with reduced IT by youth.

Julia Berteletti and David Buller at SBM

A team led by Dr. Carolyn Heckman from Rutgers University and Dr. David Buller from Klein presented a poster characterizing the IT policy landscape of U.S. states at the 44th Annual Sessions and Meeting of the Society of Behavioral Medicine in Phoenix, Arizona on April 26-29, 2023. The poster was entitled “Comparison of the stringency of indoor tanning bills regarding minors that passed and failed in state legislatures over the last 30 years.”

The research team coded 107 state IT law documents and compared passed laws to failed bills (proposed but not voted on or proposed but voted down), using a validated coding tool that assessed the presence of age bans, parental consent/accompaniment, warnings, operator requirements, and enforcement. Component codes were scaled on 10-point stringency measures (0=no regulation, 10=very strong regulation). Component and total summed scores were calculated, with higher scores indicating more stringent IT restrictions.

Between 1991 and 2022, 46 states and the District of Columbia passed a law on IT, with 23 banning access to IT facilities by minors under age 18. By contrast, 60 bills on IT failed to pass in 31 states since 2008. However, stringency of laws is weak, overall, which may explain why recent research found low compliance of IT facilities with regulations and continued IT among minors. Failed bills without minor bans were less stringent than similar passed laws, on nearly all components. Failure may have presented advocates opportunities to improve stringency of subsequent bills and time to garner more support for IT restrictions. In fact, less stringent bills may have failed because they had less support from outside constituencies (for example, medical societies and public health advocates) and among legislators. To gain insight into this public health legislation process, we are interviewing key informants from states with recent policy activity.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Co-authors included Ms. Julia Berteletti from Klein Buendel and Ms. Anna Mitarotondo from Rutgers University.

Effects of Engagement with a Social Media Campaign to Reduce Indoor Tanning

Effects of Engagement with a Social Media Campaign to Reduce Indoor Tanning

A paper by Klein Buendel scientists, staff, and collaborators published in the Journal of Health Communication reports on a secondary analysis of engagement effects from a social media campaign. The campaign, called Health Chat, was aimed at reducing mothers’ permissiveness for indoor tanning (IT) by their teenage daughters.

In the study, over 800 mothers with daughters aged 14-17 were recruited in 34 states that did not ban IT by minors under age 18 for a randomized trial. Follow-up assessments were completed at the end of the intervention (12 months) and six months after that (18 months). Daughters’ baseline and follow-up responses were analyzed also. Mothers received a Facebook feed on adolescent health topics that included posts about preventing IT (intervention) or prescription drug misuse (control).

Engagement was measured by extracting reactions (such as like or sad) and comments posted by mothers to the campaign posts. Overall, 76.4% of posts received a reaction and/or comment. Mothers who engaged with IT posts were less permissive of daughters’ IT immediately at the end of the campaign and six months after the intervention than mothers who did not engage with the posts.

Social media is a large part of the media diets of many parents and show some promise for health behavior change interventions. Social media posts need to both reach and engage parents, especially in social media like Facebook whose algorithm prioritizes posts from feeds that receive more views, reactions, and comments. This is to ensure that the posts appear in participants’ news feeds so well-crafted health communication can influence them. The authors conclude, however, that more work is needed on strategies to engage individuals with social media posts in the context of improving public policies that restrict minors’ access to IT facilities.

This research was funded by a grant and supplement from the National Cancer Institute (CA192652; Dr. David Buller and Dr. Sherry Pagoto, Multiple Principal Investigators). Collaborating authors include Dr. Kimberly Henry from Colorado State University; Dr. Katie Baker and Dr. Joel Hillhouse from East Tennessee State University; Jessica Bibeau from the University of Connecticut; and Dr. Barbara Walkosz and Julia Berteletti from Klein Buendel.

Indoor Tanning Policy and the Impact of COVID-19 on Tanning Facilities

Indoor Tanning Policy and the Impact of COVID-19 on Tanning Facilities

Julia Berteletti from Klein Buendel presented findings from a study on U.S. indoor tanning legislation efforts related to reduced indoor tanning by minors at the 43rd Annual Meeting & Scientific Sessions of the Society of Behavioral Medicine in Baltimore, MD, April 6-9 2022.

Skin cancer is a significant and expensive public health problem, with approximately 5 million Americans treated at a cost of over $8 billion annually. Indoor tanning (IT) is a well-established cause of melanoma and keratinocyte carcinomas.

Julia Berteletti Presenting at SBM

IT is regulated in two main ways: states restricting minor access and the U.S. Food and Drug Administration (FDA) regulations to minimize harm. Since 2012, 22 states and the District of Columbia adopted IT bans for all minors, ten banned some minors by age, and 12 required parental consent/accompaniment, but six have no law, primarily due to failed legislation. Seven states proposed new legislation in 2021. Additionally, FDA regulations (e.g., protective eyewear, session duration) exist to minimize harm from IT devices.

Recent evidence suggests that more stringent laws (for example, age bans vs. parental consent laws) are associated with less youth IT. Policy enforcement provisions and compliance with policies are also essential components of effective IT policy implementation, but enforcement and compliance are currently variable and inadequate. We are currently coding 102 state IT law documents that were proposed, passed, or failed, and 4 accompanying regulatory documents, using a validated coding tool. Documents are being assessed for regulation stringency, type of ban, warnings provided, operator requirements, and enforcement provisions.

Additionally, results show that beginning in March, 2020, in addition to state-level mandates, there have been additional guidelines and restrictions for IT salons due to the COVID-19 pandemic.  From March 2020 to April 2020, 49 states and the District of Columbia required salons to close to customers and reopened between April 2020 and December 2020 with varying restrictions, such as requiring appointments for services, requiring patrons to wear masks in public areas, and increasing ventilation in salons. Enforcement of these pandemic restrictions is unclear. Restrictions likely resulted in permanent salon closures and lower IT rates in 2020 but it is unknown how IT rates will be affected long-term, especially given the option for home tanning. Additional descriptive results of the policy coding and COVID-19 restrictions will be presented.

These data will help determine whether certain bill characteristics such as stringency or enforcement requirements are associated with law passage or not or bill stringency has increased over time, and the initial impact of the pandemic on IT policies. These findings will have implications for IT behavior and, ultimately, skin cancer incidence.

This research is funded by the National Cancer Institute (CA244370; Dr. Carolyn Heckman, Rutgers University, and Dr. David Buller, Klein Buendel, Multiple Principal Investigators). Authors collaborating on this conference poster include Julia Berteletti and Allyson Montalvo from Klein Buendel; and Anna Mitarotondo from Rutgers University.

Collaborator Spotlight:
Dr. Carolyn Heckman

Collaborator Spotlight:
Dr. Carolyn Heckman

Dr. Carolyn J. Heckman is an Associate Professor of Medicine and Co-Leader of the Cancer Prevention and Control Program at the Rutgers Cancer Institute of New Jersey. She received a BA in Psychology from Brown University and PhD in Counseling Psychology from the University of Iowa. She completed a postdoctoral fellowship in health psychology and addictions at Virginia Commonwealth University. She is also a licensed psychologist.

Dr. Heckman has published more than 100 research papers and presented at many national and international conferences. Much of her work focuses on skin cancer prevention and detection. Her other interests include online interventions and tobacco use and cessation. She has been funded numerous times by the National Cancer Institute and has also received funding from the American Cancer Society and Pfizer, Inc.

In addition to her research, Dr. Heckman is a member of the NIH Community Level Health Promotion study section and she is on the Editorial Board of the journal Translational Behavioral Medicine. She is the Founder/Leader of the Cancer Institute of New Jersey’s Dissemination and Implementation Science Working Group. Dr. Heckman has served on several steering and advisory, grant review, search committee, training, and other committees and community groups. For example, she served as the National Chair of the Don’t Fry Day skin cancer prevention awareness campaign sponsored by the National Council on Skin Cancer Prevention.

Currently, Dr. Heckman is a Co-Investigator on a five-year R01 study called “A Multi-Level Investigation of U.S. Indoor Tanning Policy Enactment, Implementation, Compliance, Impact, and Economics” with Klein Buendel’s Dr. David Buller. The goals of this research project are to complete three specific aims: 1) conduct a comparative case study to elucidate the indoor tanning legislation adoption process; 2) use a pseudo-patron (confederate) assessment, national survey, and archival data to investigate indoor tanning legislation implementation, as well as indoor tanning and sunburn outcomes among adolescents and young adults; and 3) integrate data from the first two aims and external data to assess economic effects relevant to policy sustainability of indoor tanning stringency, enforcement, and compliance.

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Persisting Effects of the Health Chat Program

Persisting Effects of the Health Chat Program

The use of indoor tanning facilities by minors is a public health concern. In an effort to reduce risk for skin cancer, the Health Chat social media intervention was launched by Klein Buendel researchers and their colleagues to reduce mothers’ permissiveness toward their teenage daughters’ indoor tanning behavior.

For the Health Chat study, mothers with daughters aged 14-17 were recruited in 34 states that do not ban indoor tanning by minors. Participating mothers received an adolescent health social media campaign in Facebook private groups. Half of the mothers were in a group in which the health campaign included posts about preventing indoor tanning (intervention) and the other half, included posts on preventing prescription drug misuse (control). Follow-up surveys with mothers at 12 months and 18 months measured indoor tanning permissiveness, attitudes, intentions, communication, behavior, and support for state indoor tanning bans.

Analysis of the 18-month follow-up data from the Health Chat social media intervention was e-published recently in Cancer Epidemiology, Biomarkers & Prevention. The research was led by Dr. David Buller from Klein Buendel and Dr. Sherry Pagoto from the University of Connecticut.

The methods and results of this randomized trial are detailed in the publication. Data analysis showed that at 18 months after the intervention, mothers in the intervention group were less permissive of indoor tanning by daughters and had greater self-efficacy to refuse daughter’s indoor tanning requests than mothers in the control group. Intervention-group mothers also had lower intentions to indoor tan themselves and were more supportive of bans on indoor tanning by minors than control-group mothers. In addition, daughters in the intervention group expressed less positive attitudes toward indoor tanning than daughters in the control group.

In summary, the Health Chat social media intervention may have influenced mothers’ decisions to withhold permission for their daughters to indoor tan for six months after the end of the program. Mothers’ support for bans on indoor tanning by minors also appears to have persisted.

This research was funded by a grant and supplement from the National Cancer Institute (CA192652; Dr. David Buller and Dr. Sherry Pagoto, Multiple Principal Investigators). Collaborating authors include Dr. Katie Baker and Dr. Joel Hillhouse from East Tennessee State University; Dr. Kimberly Henry from Colorado State University; Jessica Bibeau from the University of Connecticut; and Dr. Barbara Walkosz, Julia Berteletti and Alishia Kinsey from Klein Buendel. 

Results of a social media campaign to prevent indoor tanning by teens

Results of a social media campaign to prevent indoor tanning by teens

Results of the Health Chat social media intervention to reduce mothers’ permissiveness toward their teen daughters’ indoor tanning (IT) behavior have been published in Preventive Medicine Reports.

During the intervention, participating mothers received an adolescent health social media campaign in Facebook private groups. Half of the mothers were in a group in which the health campaign included posts about preventing IT (intervention) and the other half, included posts on preventing prescription drug misuse (control). Health Chat was designed by the research team based on an integrated conceptual framework of social cognitive theory, transportation theory, and diffusion of innovations theory.

Given mothers’ high use of social media, the research team, led by Klein Buendel Director of Research, Dr. David Buller, and Dr. Sherry Pagoto from the University of Connecticut, evaluated a social media campaign aimed at mothers to prevent IT by their daughters in a randomized trial that tested two hypotheses:

H1: The social media campaign on IT will significantly reduce (a) mother’s permissiveness regarding their daughter’s IT, (b) their daughter’s perception of maternal permissiveness toward IT, and (c) both mother’s and daughter’s IT relative to the control condition.

H2: A statistically significantly greater number of mothers will support a ban on IT for minors in the intervention group compared to the control condition.

Study methods, data, and results are detailed in the Preventive Medicine Reports’ publication and indicate that a social media campaign may be an effective strategy for convincing mothers to withhold permission for IT from their teen daughters, in an effort to reduce risk for skin cancer.

This research was funded by a grant and supplement from the National Cancer Institute (CA192652; Dr. David Buller and Dr. Sherry Pagoto, Multiple Principal Investigators). Collaborating authors include Dr. Katie Baker and Dr. Joel Hillhouse from East Tennessee State University; Dr. Kimberly Henry from Colorado State University; Jessica Bibeau from the University of Connecticut; and Dr. Barbara Walkosz and Julia Berteletti from Klein Buendel. 

Adopting Policy to Eliminate Indoor Tanning

Adopting Policy to Eliminate Indoor Tanning

Dr. David Buller from Klein Buendel joined two other behavioral scientists to publish a Viewpoint in JAMA Dermatology in April calling on dermatologists and others to support legislative efforts and other policies in their local areas to help dramatically curtail indoor tanning in the United States. The other two authors were Dr. Carolyn Heckman from the Rutgers Cancer Institute of New Jersey and Dr. Jerod Stapleton from the University of Kentucky.

The Viewpoint describes policy and regulation as “among the most effective strategies for influencing health behaviors and public health.” Indoor tanning restrictions in multiple states are helping to reduce skin cancer incidence and death.  Achieving continued and additional restrictions will require concerted research, advocacy, and policy efforts to overcome remaining barriers to new laws and to close lingering gaps in existing laws.

In their editorial, the authors put out a Call to Action to dermatologists to increase their awareness of local indoor tanning laws, or lack thereof, and to educate their patients, legislators, school boards, local business groups, and others about the dangers of indoor tanning and the need for more restricted use, especially by minors.

The Viewpoint was published online in JAMA Dermatology on April 28, 2021.

Results of a Social Media Campaign to Prevent Indoor Tanning by Teens: A Randomized Controlled Trial

Results of a Social Media Campaign to Prevent Indoor Tanning by Teens: A Randomized Controlled Trial

Indoor tanning (IT) increases the risk of developing melanoma. A social media campaign to reduce mother’s permissiveness toward their teenage daughters’ IT was designed and evaluated by Dr. David Buller, Director of Research at Klein Buendel, and his research team. He gave a presentation on the Health Chat campaign at the virtual 71st Annual International Communication Association Conference, May 27-31, 2021.  

A total of 869 mothers of teenage daughters aged 14-17 in 34 states without bans on IT by minors were enrolled in a randomized controlled trial with two assessments, baseline and 12-month follow-up in 2017-19. A year-long adolescent health campaign was delivered to all participants. The intervention group received posts on preventing IT while the control group received posts about preventing prescription drug misuse. Mothers completed assessments of permissiveness for daughters to indoor tan, self-efficacy for refusing permission, communication with daughters about avoiding IT, attitudes and intentions toward IT, IT behavior, and support for state IT bans. Daughters (n=469; 54%) completed the assessments at baseline and at 12 months.  

At the 12-month follow-up, intervention-group mothers were less permissive of IT by daughters, reported more communication with daughters about avoiding IT, and had lower intentions to indoor tan than control-group mothers. Daughters confirmed intervention-group mothers communicated about IT and shared IT posts more than control-group mothers.  

Overall, a social media campaign may be an effective strategy to convince mothers to withhold permission for IT, which may help increase the effectiveness of state laws designed to reduce IT by minors by requiring parental permission.  

This research was funded by a grant and supplement from the National Cancer Institute (CA192652; Dr. David Buller and Dr. Sherry Pagoto, Multiple Principal Investigators). Collaborating authors include Dr. Sherry Pagoto and Jessica Bibeau from the University of Connecticut; Dr. Kimberly Henry from Colorado State University; Dr. Katie Baker and Dr. Joel Hillhouse from East Tennessee State University; and Dr. Barbara Walkosz and Julia Berteletti from Klein Buendel.