Elsevier

Preventive Medicine

Volume 123, June 2019, Pages 299-307
Preventive Medicine

Review Article
Impact of legislation on youth indoor tanning behaviour: A systematic review

https://doi.org/10.1016/j.ypmed.2019.03.041Get rights and content

Highlights

  • Small decreases were observed in youth indoor tanning prevalence after legislation.

  • Youth indoor tanning prevalence was lower in states with indoor tanning legislation.

  • Greater legislative stringency, enforcement, and compliance may decrease youth indoor tanning prevalence.

Abstract

Jurisdictions around the world have implemented indoor tanning legislations, which aim to protect all individuals, especially youth, from dangers of artificial ultraviolet radiation exposure. The objective of this study was to conduct a systematic review to synthesize the available peer-reviewed literature to determine whether indoor tanning legislation has impacted the prevalence of youth indoor tanning. Following PRISMA guidelines, six databases were searched in 2016. Reference lists from relevant articles were also searched. An updated literature search was conducted in 2018. Each article was critically appraised using a merged checklist created from two previously validated checklists. All articles meeting the inclusion criteria were retained after appraisal. Seven studies, all conducted in the U.S., met the inclusion criteria. All studies used an observational, cross-sectional design. There were small absolute decreases in youth indoor tanning prevalence after legislation vs before (n = 3, mean = 3% decrease, range = 1%–6% decrease). Prevalence of youth indoor tanning was significantly lower in states with indoor tanning legislation vs states without legislation (n = 4, mean = 5% lower, range = 1%–18% lower). Prevalence of youth indoor tanning was lower in states with longer standing indoor tanning legislation vs states with more recently implemented legislation (n = 2, mean = 9% lower, range = 2%–20% lower). Indoor tanning legislation is generally associated with lower indoor tanning prevalence among youth. The small percent differences equate to millions of youth at the population level. Longer time lapses from legislation implementation to evaluation, coupled with greater enforcement, compliance, legislative stringency, and public education may result in even more pronounced declines in youth indoor tanning prevalence.

Introduction

Indoor tanning is a health risk behaviour requiring legislative efforts to curb its use and prevent disease. Artificial UV exposure can have many negative health impacts, especially for skin (Canadian Cancer Society, 2017). Exposure to artificial UV radiation causes DNA damage and mutation of skin cells, which can ultimately result in skin cancer (El Ghissassi et al., 2009).

Despite the health risks, the popularity of indoor tanning remains high, especially among youth and young adults (Nadalin et al., 2016). In 2013, an estimated 11.3 million Americans used indoor tanning devices, with 1.6 million of them under the age of 18 (Guy et al., 2016). Results from the 2017 American Youth Risk Behaviour Survey indicate that 5.6% of high school students used an indoor tanning device at least once over the previous year (Kann et al., 2018). Additionally, in 2014, an international systematic review of 16 countries found approximately 18% of adolescents had been exposed to indoor tanning in the past year (Wehner et al., 2014). Indoor tanning before the age of 35 increases the lifetime risk of melanoma by 59% (Boniol et al., 2012). Together, this points to adolescence as a critical period for UV exposure (Wehner et al., 2012). In response, a growing number of governments have implemented legislation to reduce indoor tanning access and use (Pawlak et al., 2012). Most of these legislations are focused on banning youth, as recommended by the WHO (The World Health Organization, 2003). In 2011, 11 countries had legislation banning youth under the age of 18 from indoor tanning (Pawlak et al., 2012). Specifically, in the U.S., 44 states and the District of Columbia have legislation restricting youth indoor tanning (National Conference of State Legislatures, 2018).

While numerous jurisdictions have indoor tanning legislation restricting youth access, the results of studies on the impact of this legislation have not been systematically compiled. To address this research gap, we conducted a systematic review to synthesize the available peer-reviewed literature to determine whether indoor tanning legislation has impacted the prevalence and frequency of youth indoor tanning and to characterize any such changes.

Section snippets

Search strategy

Following PRISMA guidelines (Moher et al., 2010), six databases were systematically searched in November 2016 to obtain peer-reviewed literature concerning the impact of indoor tanning legislation on youth tanning. Search terms, published elsewhere (Reimann et al., 2018), were used in the following databases to yield articles: PubMed (n = 6447), Medline (n = 5241), JSTOR (n = 133), ABI/INFORM (n = 149), Business Source Complete (n = 197), and PsycINFO (n = 230). In total, 12,398 articles were

Study characteristics

Although there were no geographic restrictions in the search, all studies included in this review were conducted in the U.S. (n = 7). Of these studies, two studies included one state (Coups et al., 2016; Simmons et al., 2014), one study included two states (Blashill and Pagoto, 2017), one study included 32 states (Guy et al., 2014), one study included 34 states (Mayer et al., 2011), one study included 37 states (Qin et al., 2018), and one included a national scope (Cokkinides et al., 2009). All

Discussion

This systematic review of seven U.S.-based studies describes a lower trend in the prevalence of youth indoor tanning associated with indoor tanning legislation. This was true for comparisons before and after legislation, among states with and without legislation, for states with complete age restrictions (no parental permission), and for longer standing compared to newly implemented legislation. The percent differences in youth indoor tanning prevalence found in this review were, on average,

Limitations

Given that many countries have indoor tanning legislation, it is important to study and synthesize the impact of these legislations on prevalence of use in other jurisdictions outside of the U.S. We also only included studies that were written in English. Three studies in the review had some overlapping data but were retained because the results, years, and states evaluated differed.

Legislation content and stringency varied across jurisdictions. As well, studies differed in terms of

Conclusions

Overall, indoor tanning legislation was associated with a slight decrease in the prevalence of indoor tanning use by youth but did not eliminate youth tanning; however, small percent differences equate to millions of youth at the population level potentially avoiding a risky exposure. Variations in legislative impact may be due to differences in stringency of legislation or time lapse from implementation to evaluation, among other factors. Current indoor tanning legislations appear to be

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The findings and conclusions presented in this paper are those of the authors and do not necessarily reflect the views of the University of Guelph. Author tasks were as follows: Jessica Reimann and Dr. Jennifer McWhirter had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and

References (35)

  • V. Cokkinides et al.

    Indoor tanning use among adolescents in the US, 1998 to 2004

    Cancer

    (2009)
  • K. Diehl et al.

    Use of sunbeds by minors despite a legal regulation: extent, characteristics, and reasons

    J. Public Health

    (2013)
  • S.H. Downs et al.

    The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions

    J. Epidemiol. Community Health

    (1998)
  • G.P.J. Guy et al.

    State indoor tanning laws and adolescent indoor tanning

    Am. J. Public Health

    (2014)
  • G.P. Guy et al.

    The potential impact of reducing indoor tanning on melanoma prevention and treatment costs in the United States: an economic analysis

    J. Am. Acad. Dermatol.

    (2016)
  • L.F. Heilig et al.

    A case for informed consent? Indoor UV tanning facility operator's provision of health risks information (United States)

    Cancer Causes Control

    (2005)
  • E.J. Hester et al.

    Compliance with youth access regulations for indoor UV tanning

    Arch. Dermatol.

    (2005)
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