In February 2012, Connecticut considered a bill that would have made it the fourth state to ban tanning for most teens. Ferrucci and Hurd were among those testifying in its favor, but the bill died in committee. A similar measure is being considered by the legislature in early 2013. Current Connecticut law allows adolescents 16 and over to tan without parental permission.
In any case, such laws don't go far enough, says Ferrucci. In 2009, months after tanning devices landed on the Group 1 carcinogen list, Brazil outlawed cosmetic artificial tanning. "That would be potentially the ideal," she says.
Such proposals meet with strong opposition from the tanning industry. The Indoor Tanning Association (ITA), which represents tanning businesses and sunlamp manufacturers, supports parental consent laws for minors. But it has objected to other regulatory efforts. An ITA representative opposed to the Connecticut bills argued that barring minors from indoor tanning will lead them to tan outdoors or at home "in an unsupervised and reckless manner." (Hurd recalls being told by indoor tanning staff that the activity was "safer than tanning outside.")
"We agree that overuse and sun burning are risk factors," says the ITA's executive director, John Overstreet. "But the message that's out there is a way over-the-top message. It is aimed at destroying this industry."
Indoor tanning, he added, is "the same thing as the sun. You have the same risks, and you have the same benefits."
However, many people who tan indoors report getting burned during their sessions. Among the BCC cases in Connecticut, 28% reported being burned from indoor tanning and 16% reported four or more burns. Another study of melanoma in Minnesota found a similar figure, with 22% reporting a burn from indoor tanning. And the relationship between indoor tanning and increased risk of both cancers holds true even in people who did not experience burns during indoor tanning.
In particular, the industry's marketing message emphasizes the fact that tanning triggers vitamin D production. Could discouraging UV exposure in an effort to prevent skin cancer lead to a rise in vitamin D deficiency and its associated problems? One group of Norwegian researchers calculated that if people in their country were to receive more sun exposure, there might be 300 more melanoma deaths per year, but 3,000 fewer annual cancer deaths overall from the associated increase in vitamin D levels (though the latter number was based on only one paper). They also pointed out that such exposure could offer protection against noncancerous diseases, such as multiple sclerosis and diabetes, to which vitamin D deficiency has been linked.
"This message, this constant drumbeat, scaring people about tanning and ultraviolet light exposure - there's a good chance there's a bigger underlying health problem being created," says Overstreet. "Most people are vitamin D deficient because they hear this message. You have people scared to death of being in the sun."
But when a panel of the National Academy of Sciences convened to review vitamin D intake recommendations (the results were published in 2010), it found that there are only inadequate and inconsistent data about a relationship between vitamin D intake and cancer risk. Moreover, says Mayne, who was a member of the panel, statements about epidemic vitamin D deficiency are unfounded: In fact, only 3% of adults in the United States are at risk of deficiency, with another 18% at risk of inadequacy. "The populations in the United States that tend to have low vitamin D status are people with deeply pigmented skin," she says. "Those aren't the people who are in the tanning booths."
Adds Cartmel, "If you are deficient, you can just take a supplement, which is much safer."
As for the industry's warnings about outdoor tanning, Mayne counters that while outdoor sun exposure is an important factor for skin cancer risk, most people's lives don't allow time for regular outdoor tanning - but people can easily tan indoors several times a week. In addition, exposure to outdoor UV is inherently limited in many northern climates.
Still, could indoor tanning advocates have a point? Is it safe or healthy to get vitamin D from any amount of UV radiation?
"When we look at what people actually take in from food versus what their blood status is, it is very clear that people in the United States are getting a significant amount of vitamin D from UV," says Mayne. "I don't think anybody's trying to tell people that we have to shield every single ray of UV. I think that's unreasonable. But I think indoor tanning is a completely different ballpark, because it is an unnatural, intense exposure that has now been associated with rising rates of these cancers."
The sun emits radiation in many wavelengths, but what reaches the earth is mostly UVA and a small amount of UVB. UVA darkens the skin immediately, while UVB causes sunburn and delayed tanning. Tanning lamps emit mostly UVA, too. Overstreet says the vast majority of sunlamps have the same spectral output as the noonday equatorial sun, while the industry website SmartTan.com estimates that most sunlamps are two to four times stronger than summer sun.
But there is evidence that they are much more intense than that. One 2002 Swiss study of tanning bed lamps found that they emit 10 to 15 times more UVA than what reaches the Earth's surface at midday at intermediate latitudes (which receive about 70% of the solar energy that the equator does), a finding in accord with what individuals experience when they tan indoors. "If you're on a beach in California for 10 minutes, [most people are] not going to develop a tan," says Mayne. "But you go into a tanning bed, and within 10 minutes of exposure, you're getting tan."
Moreover, sunlamp manufacturers are tweaking the technology, offering options like UVB-rich high-speed lamps and "high-pressure/high intensity" tanning. "People tell us that the duration of the sessions is shorter now than it used to be in the past, so obviously the bulbs are more intense than they were," Mayne says.
In short, Mayne sees indoor tanning as a new human experiment. "We don't have that equivalent of UV exposure in the outdoor environment."
Mayne and Ferrucci are not finished examining indoor tanning. With Cartmel and other colleagues, they are investigating the genetics of both skin cancer susceptibility and tanning addiction. They also want to better understand how people's indoor tanning behaviors change after a skin cancer diagnosis, as their other findings indicate that some 14% of BCC patients continue to engage in indoor tanning after their diagnosis. "We're just trying to work out why these people are going back and still participating in a risky behavior, when they are actually at quite high risk of getting another skin cancer," says Cartmel.
They are also studying the natural history of subsequent skin cancers in people who have already been diagnosed once at a young age. Though mostly nonfatal, these cancers cost the country a great deal in the aggregate. "As people are starting to get them younger, they have a whole lifetime to keep getting these cancers," she says.
Ferrucci recently received a five-year grant from the American Cancer Society to study indoor tanning prevention and cessation. She is developing an online intervention to discourage women in their twenties from using tanning beds, as well as conducting focus groups with young adolescent girls to pinpoint why they might start this behavior in the first place. "One of the things that's motivated me in doing this research is that this is a behavior that individuals can change," Ferrucci notes.
Indeed, for Mayne, Ferrucci and Cartmel, one thing is clear: If thousands of skin cancers can be prevented by simply avoiding UV light, then public health professionals have a clear responsibility to try to make that happen.
Hurd regrets her former tanning habit and now advocates for stricter regulation. Though her melanoma was excised, she must undergo frequent cancer surveillance for the rest of her life. "I think this is a public health issue comparable to that of the Big Tobacco industry of our generation," she says. A ban for minors "would have made an enormous difference for me had it been in place when I was 17."
Mayne has heard such regrets over and over again. "Half of the people in our study started using tanning beds before the age of 17, and then, in their twenties and thirties, many are regretting that choice," says Mayne. "They often say, 'I wish somebody had told me. I wish somebody had worked toward this when I was a kid.' It's a completely preventable exposure."
Source: Yale University
