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Beauty has its price. Theprice of a ‘healthy’ suntan – particularly from indoor tanning spas – could bean early deathbed, healthcare professionals say. The $5 billion tanningindustry has proclaimed ‘a new BronzeAge,’ backing health claims with its own scientific studies. But recent researchsheds light on indoor tanning’s links to potentially deadly skin cancers, andother skin and health problems that are no day at the beach
The healthy glow of a bronze sun goddess is an icon in the South, and the fast-growing indoor tanning industry is helping create that image of health year-round.
Though federal and many state regulations prohibit the industry from saying so directly, the indoor tanning industry has subtly promoted itself as a healthy alternative to outdoor sunbathing and touted other health benefits of regular exposure to “controlled” ultraviolet radiation from the bulbs in its tanning beds.
“It’s a seasonal business,” says John Overstreet, executive director of the Indoor Tanning Association. “Starting about February, whenever people start thinking about bathing suits and spring break, they just want to get some color so they don’t scorched their first day out and ruin their vacation.”
But countless physicians and scientists and their national and international organizations hold a far dimmer view: Tanning spas are attracting younger and younger patrons, many of whom go several times weekly, year-round (addictively, research suggests). Increasing numbers of patients, at younger ages (particularly women) are being diagnosed with skin cancer. The most deadly skin cancer, malignant melanoma, has skyrocketed. And while the indoor tanning industry appears to be strictly controlled on paper in about half the states, the vast majority of regulatory agencies put little or no priority on enforcing compliance to the regulations.
“Tanning beds are terrible,” said Dr. Harriett Van Hale, a Greenville dermatologist.
“I’m amazed the FDA hasn’t banned them.”
Dr. Michael Franzblau is blunter on the tanning industry: “In most states, there’s no licensure requirement, where they’re selling cancer, while barbers and beauticians must be licensed. It’s an anomaly in law.”
“The evidence is overwhelming, both scientifically and epidemiologically, that indoor tanning induces melanoma and promotes propagation of other skin cancers over and over,” continues Franzblau, a clinical professor of dermatology at the University of California, San Francisco, who drafted California’s 1988 law intended to regulate spas.
“The fact of the matter is that the public is unsuccessfully informed about the radiological health in branding, labeling or otherwise, and aren’t interested in this because the lobbying efforts of the indoor tanning industry have been very effective,” Franzblau says. “The tanning industry bases its claims on outrageous lies and scientific papers.”
Dangerous Waves
Natural sunlight contains a mixture of both short-wave UVB and longer-wave UVA rays, exposure to both of which can lead to premature aging of the skin and both increase a person’s risk of developing skin cancer. You can get sunburn from “natural” outdoor sunbathing, because it’s the UVB rays that cause the burn.
Most U.S. tanning beds use low-pressure bulbs that emit UVA and UVB rays, but predominantly the longer-wavelength UVA rays, as UVB rays are filtered out through an acrylic shield. While UVB causes sunburns, UVA typically doesn’t, without longer exposure times. That’s why many states regs, including DHEC’s, require tanning spa operators to perform a “skin evaluation” of the client and start with limited controlled times in the beds.
The longer UVA wavelengths in a tanning bed - as much as 100 times the amount that would come from spending the same amount of time in the sun - has higher energy that penetrates deeper into the skin, without the UVB rays that damage the outer layer of the skin (sunburn).
Indeed, suntan beds’ UVA rays can provide a “base tan” to prevent sunburn outdoors from the sun’s added UVB rays. But that’s just the rub: The unwitting sunworshipper may not get sunburned at a spa (though some do), but a tanning bed’s UVA rays combined with the sun’s rays creates enough cumulative UVA radiation to penetrate the epidermis into the skin’s underlying tissues. That can cause DNA mutations leading to cancer - 10, 20 or 30 years down the line.
And while the skin may not appear damaged, UVA rays damage the collagen and elastin fiber beneath the skin, so “the skin has less elasticity, and that’s why people look old and wrinkled,” Van Hale said. “It damages the springs of the mattress, so to speak.”
The ITA’s Overstreet counters that “the whole goal of indoor tanning is that you don’t get burned, the UV light is very controlled, and you know exactly how much you’re getting because the lamp outputs are strictly controlled by the FDA. It’s a short period of time, and a maximum time you can be in a bed. The operators’ job is to look at you and decide how much sun you can take.”
Feel the Burn
The tanning industry’s key selling point: You’ll tan without burning, so it’s safer than the sun; the more frequent you go to the tanning bed, the deeper the tan, thus, the more protection from the sun.
And that’s where tanning spas, according to the majority of the medical and scientific community, become more dangerous than the sun.
Officially, the indoor tanning industry can’t deny links to skin cancer, but it defuses the malignant melanoma connection in carefully hedged language: “The UV rays emitted by indoor tanning bulbs do not emit sufficient energy to penetrate past the skin layers. Thus, despite claims and rumors to the contrary, internal organs are not directly impacted by longer wave UV light,” reads the 50-page FAQ provided by the leading tanning bulb manufacturer, Kennesaw, Ga.-based Wolff System Technology Corp.
Internal Organs? No (the document makes no mention that the skin is an organ). Internal tissues? Undoubtedly, yes.
The longer-wave UVA rays, while they may not cause a burn, penetrate more deeply into the skin, beneath the epidermis and into cells in underlying tissues, potentially mutating their DNA into cancerous cells, including melanoma, according to dermatologists.
The tanning industry and spa operators can’t refute the evidence that UV radiation can lead to skin cancer, specifically basal cell carcinoma and squamous cell carcinoma, which cause unsightly lesions (often on the face and shoulders), requiring surgical removal. But recently, the tanning industry heated up the “debate” by pointing to studies suggesting that many Americans don’t get enough vitamin D, which the skin makes from the sun’s UV rays, and more “controlled” sun exposure could help prevent colon cancer, breast cancer and other diseases.
Dermatologists, other health care professionals and scientists insist that there’s never “controlled” UVA exposure; it’s all around you.
“You never know what amount you’re getting,” says Dr. Matthew Bryan, another Greenville dermatologist, adding the problem is escaping UVA radiation. “Besides saying they’re getting a ‘protective tan’ before going to the beach, these vitamin articles and hype are the main reason some patients say, ‘ha, ha, ha, we told you so.’ ”
Bryan says the huge body of research showing that we get too much UVA radiation - which penetrates glass, which we absorb during the night and throughout the winter - far outweigh studies showing vitamin D deficiency.
Franzblau calls indoor tanning’s lobbyists “extremely able propagandists.”
“These claims that vitamin D does everything from growing toenails to curing breast cancer have not one scintilla of proof,” he says. “There’s no shortage of fakery among the public attitudes that equate tanning with health.”
The exact opposite is true, he says: “The beating on your skin goes on year after year, and there’s going to be trouble when you add UVA that’s so subtle that you don’t feel a burn.”
A huge body of evidence from studies dating back to the early 1990s has shown high correlations between UVA exposures to melanoma development, specifically among those who used high UVA tanning devices, Franzblau says.
“These days, tanning beds are almost exclusively UVA, which penetrates the skin more deeply than the sun, causing not only skin cancer damage, but aging it prematurely,” says Dr. Sherry Hsuing of the American Academy of Dermatology and a dermatologist at New York University Medical School. “The message that a person should get a tan before going to the Caribbean isn’t helpful. All you’re doing is adding more UVA radiation and getting a higher cumulative dose of UVA.”
When the skin darkens, there’s an immediate release of melanin and the skin becomes thicker, enabling a tanner to acclimate to a higher exposure.
“When these UVA rays penetrate the skin, it causes breakages in the DNA strands that can’t repair themselves, which directly lead to skin cancer,” says Dr. Matthew Miller, a Greenville dermatologist. “I’ve seen a major increase in skin cancer among patients who use tanning beds. Not in teenage girls, but some in their 30’s and 40’s who used spas as teens.”
“Sure, you’re safe from getting sunburned,” says Miller. “But sunburn’s not the only problem. It used to be we thought UVB was the culprit, because getting sunburned in youth led to cancer later, so people thought if they weren’t burned in a sun bed, there was less chance of cancer. But the new way of thinking - for 10 years at least now - is that UVA just adds to the risk.”
Getting a “base tan” to avoid sunburn, Miller says, is “like smoking a pack of cigarettes when you start smoking, and you won’t cough.”
“It creates a false sense of security,” adds Greenville dermatologist Dr. Eric Baker. “The sun and tanning booths are both sources of skin cancer. Both cause damage.”
Dr. Patricia Westmoreland, another Greenville dermatologist who closely follows legislation and regulation of tanning spas, says the SC Medical Association and American Association of Dermatology has considered pushing for a ban on tanning spas in the General Assembly, or at least pushing for greater DHEC control, but no legislator has championed the cause.
“A tan is your body’s response to injury, and it’s not a normal thing,” Westmoreland adds. “No tan is safe and very few people don’t get one.”
It’s long been known that UVB rays cause cancer, so when beds came out with Wolff bulbs that emit primarily UVA, the implication was they were safe, Westmoreland says.
“As it turns out, that’s not true, because UVA penetrates more deeply, therefore more likely to give you melanoma,” Westmoreland says. “And a lot of other diseases are made worse by UV rays, not just skin cancer. It can activate lupus, activate herpes, while many drugs can adversely photoreact and even perfumes can photoreact into health problems. There are many reasons to be cautious with ultraviolet radiation, because it is radiation.”
UVA rays suppress the immune system, activating herpes viruses like cold sores, and at least one recent study in Canada suggests UV rays could activate dormant HIV viruses on those infected with the disease.
Westmoreland says she’s seeing melanomas in younger and younger patients, “and I really feel like they got it after going to a tanning bed,” though it’s never a certainty because the cancer may not have developed until many years after exposure. Melanoma can take 20 to 50 years to develop, she says.
Hooked on the Oompah-Loompah Look Yet another tanning spa risk: It’s addictive, as sun worshippers become hopelessly devoted to their bronze color.
“The melanocytes act as a stimulating hormone similar to an opiate, or to eliciting a ‘runners high’,” Baker says. “It’s a ‘sunbather’s high.’ I see a lot of people out of tanning beds that are drawn to it repeatedly.”
Miller, despite his stern warnings, says that “the shocking thing is that I have several patients that have gone to tanning spas - and still go - after I’ve treated several basal cell carcinoma lesions.”
One patient stands out: Miller found 15 basal cell sites below the waste on a 41-year-old patient.
“We were starting to have to cut on her quite a bit after she went to a tanning bed in April and May,” Miller says. “When she came back to be treated this fall, she said when winter comes, she’ll go back to the tanning spa, since her skin cancer had been treated.”
Past studies suggest that tanning generates the brain’s chemical endorphins creating feelings of euphoria and decreased sensitivity to pain. People literally become addicted to maintaining a deep, dark tan irrespective of the season.
Bryan recently removed a basal cell carcinoma from the leg of “an extremely tan” patient who used tanning beds, and completely stopped in favor of using a self-tanning lotion.
“But some continue to tan, regardless of how we try to educate them,” Bryan says. “They need to realize that the danger that if they get one cancer, they’re at risk for another form of cancer. If they’ve had enough exposure to have basal, they’re at risk for melanoma. There is no such thing as a healthy tan. It may be healthy looking, but it’s not.”
A study published just last month in the journal Archives of Dermatology suggests addiction to UV light could be the reason some people constantly tan in the sun or in booths, despite knowing that exposure to UV radiation from the sun or tanning beds can cause skin cancer.
Richard Wagner, the paper’s author, a dermatologist and professor at the University of Texas Medical Branch in Galveston, said he started thinking about tanning as an addictive behavior after seeing many well-tanned patients who had skin cancers. Some told him that they tried to stop tanning but felt it was out of their control. Others said that if a beach wasn’t available, they would seek out back yards or tanning salons to get their fix.
Wagner’s research team surveyed 145 beachgoers at Texas’ Galveston Island Beach in July 2002 with modified versions of questionnaires used by psychiatrists to test for addictive behavior. The survey found that women were more likely than men, and the young more likely than older people, to go to the beach for a tan. And, like drugs or drinking, people often expose themselves to UV light for longer than they originally intended, or after the effects of tanning, such as sunburn, disrupt the tanner’s social, occupational or recreational activities.
The Inny-Outty Debate
Previous epidemiological studies of human populations show strong correlations between sunburns, particularly early in life, to melanoma. As a result, the tanning industry relies on a misleading argument: that since melanoma is mainly caused by UVB-related sunburn, “controlled” UVA tanning helps prevent melanoma by building up the protective pigment melanin, according to the AAD’s Hsuing.
UVA radiation damages the tissues that produce melanin, a protective mechanism humans evolved in sunnier areas, explains Clemson University professor Lyndon Larcom, who teaches both biological sciences and physics and astronomy. People exposed to artificial UVA “are getting the same damage, but have a feeling of protection.”
As for sunbeds, “I don’t think they’re a good idea. Some have made the argument that it’s safer than tanning in the sun, but UVA rays may be a far bigger factor in developing skin cancers,” said Larcom, adding that the problem is the same for sunblocks that act solely on shorter-wave UVB rays.
Scientists have determined that a mutation occurs in a tumor suppressor gene, causing DNA breakage leading to cancer, says Larcom, who has worked with dermatologists in designing sunscreens based on raspberry extracts.
Women and Children First
More than one million new cases of skin cancer, North America’s most common cancer, are diagnosed in the United States each year, and incidence is increasing. About 96,000 of those cases are melanoma, which has more than tripled among Americans in the last 25 years. An American dies from melanoma every hour; 10,250 died of skin cancer in 2004, according to the American Cancer Society, nearly 8,000 from melanoma. More than a fifth of Americans are expected to develop some form of skin cancer during their lifetime
Those with the highest skin cancer risk: Young women, particularly teenagers.
The ITA’s Overstreet says that teenagers account for 5 percent of the industry’s business.
But Hsuing says one-third of the white U.S. teenagers (10 percent males) use tanning spas to develop a “base tan” and get some color before going on vacation. According to a recent AAD survey, more than one in four (26 percent) of those under age 25 have used a tanning bed within the last year, despite awareness of potential future consequences such as skin cancer.
“They have the perception that this can prevent sunburn because they’ve bought this line that’s completely untrue,” Hsuing says. “Indoor tanning is directly correlated to an increased risk of skin cancer, especially in women aged 20 to 40. Skin cancer is the most rapidly growing form of cancer of all people ages 20 to 40.”
The AAD has urged that all states prohibit indoor tanning for minors and also has recommended that tanning facilities not use words such as “safe tanning” or “no harmful rays” when advertising their UV tanning devices.
Meanwhile, the American Medical Association, the AAD, the American Academy of Pediatrics, the World Health Organization and even the United Nations have called for governments to pass federal legislation prohibiting minors’ use of indoor tanning equipment. The joint policy also supports a U.S. Surgeon General’s warning - linking the correlation between UV radiation, the use of indoor tanning equipment and the incidence of skin cancer - to be prominently displayed on all indoor tanning equipment.
“There is no evidence that tanning in a bed is any safer than tanning in the sun. In fact, some tanning beds release much stronger UV light than the sun does,” according to a WHO fact sheet released in March: Sunbeds, Tanning and UV Exposure.
“I definitely believe there are links between tanning beds and melanoma,” says Bryan. “In years past, the studies have been inconclusive. But a study in March 2005 looked at all the studies conducted between 1984 and 2004 and concluded a definite link.”
The study, by a research group in Vancouver, Canada, conducted an exhaustive “meta-analysis” combining the statistics of those past studies and concluded a definite link with increased melanoma risk.
“It makes perfect sense,” Bryan says. “We know UV light is a carcinogen, and the Department of Health in December 2002 said it was a carcinogen.”
“I’m definitely seeing more skin cancer among young people, in their 20s and 30s, and it’s amazing the UV exposure you get when you combine sun exposure with tanning beds,” Bryan says. “Whether or not you can attribute it totally to tanning beds, it’s affecting younger population. And it’s bad skin cancers like malignant melanoma, with the greatest increase in young women 25 to 29 years old.”
Dartmouth Medical School researchers also recently studied more than 1,400 people to see if any association between skin cancer and tanning beds exists. Almost 900 of them had either basal cell or squamous cell cancer. Each person was asked about their use of tanning beds or lamps or sun exposure.
The Dartmouth study was looking only at the association between tanning beds and non-melanoma skin cancers. But it showed those who had ever used a tanning bed were 2.5 times more likely to have squamous cell cancer and 1.5 times more likely to have basal cell cancer, the researchers report in the Journal of the National Cancer Institute’s February 2002 issue.
Those that started using tanning beds at an earlier age tended to be more likely to end up with skin cancer. For each decade younger someone was the first time they used a tanning device, they were 20 percent more likely to get squamous cell cancer - and 10 percent more likely to suffer from basal cell cancer.
The Look That Lasts
The vast majority of the medical and scientific community has long acknowledged that the sun’s UV rays cause premature aging of the skin, and that appeal to vanity: the prospect of wrinkles, “crows feet,” “frown lines,” leathery skin and looking like a big piece of beef jerky in your 40’s has been effective in getting some to cover up in the sun.
But the risk of skin cancer hasn’t taken hold, especially among the young, such as teenagers. They’ve heard it all. The youthful sense of invulnerability, most disturbing among teens, prevails: If you get skin cancer, it won’t be for 10 years (a lifetime away for them), and even a dermatologist will tell you that even if you do get melanoma, there’s a 94 percent survivability rate. And by the time they’re over-the-hill hags in their 30’s, looks won’t matter, some young women may think.
Clemson’s Larcom lectures on the UV/cancer connection in a course he teaches on cancer, but “in my experience, kids in their college age don’t really care if they see something down the road, and they do a lot more soaking than they did even five years ago,” he says.
A tan may look good, but all skin cancer treatment isn’t pretty. The cancers in Dartmouth’s study don’t kill, but require aggressive treatment with surgery, which can leave disfiguring scars if the cancer isn’t treated early. If caught early enough, Bryan says, surgery requires clearing a margin around the tumor, but often the disease spreads to lymph nodes all over the body that must be drained. Invasive melanoma requires a major surgical procedure by surgeons, using general anesthesia, not just a slice from dermatologist’s knife.
And more evidence is amassing that links tanning spa use to melanoma. As far back as 1994, a Swedish study found that 18- to 30-year-old women who visited tanning parlors 10 times or more a year had 7 times greater incidence of melanoma than women who didn’t use tanning salons, researchers reported in the American Journal of Epidemiology. Risks increased the earlier a person was exposed.
Another 1998 study in the same journal by researchers at Yale University School of Medicine showed the odds of developing melanoma for sun spa user was 1.3 times that of a non-user, with much higher risks for those who used tanning devices before age 25.
Last October, a study published in the Journal of the National Cancer Institute showed women who visited tanning salons more than once a month were 55 percent more likely to develop malignant melanoma, and the risk more than doubles for women in their 20s who frequent tanning parlors.
The eight-year study of more than 100,000 Scandinavians was the largest epidemiological study of its kinds, analyzing the lifestyle and melanoma risk for women between the ages of 30 and 50, and found that using tanning lamps during the adolescent and early adult years significantly increases skin cancer risk. Compared with women who never used a tanning spa, women between the ages of 20 and 29 who reported using artificial tanning systems once or more per months increased the risk of melanoma by about 150 percent.
Still, while the link between other skin cancers and indoor tanning is “pretty well settled,” said Dr. Vincent DeLeo, chairman of dermatology at Beth Israel Medical Center in New York, the link with melanoma is more tenuous simply due to the long period between exposure and actually developing the disease. Other factors, such as exposure to sunshine and smoking can come into play over the interim decades, he says.
But he adds, there’s no doubt that whatever mix of wavelengths of rays emitted when using a tanning bed, even one with a higher proportion of shorter-length UVB rays that mimic natural sunlight, will cause damage to the skin.
But the Wolff’s FAQ still states emphatically: “There is no conclusive evidence which substantiates that malignant melanoma is caused by gradual, moderate UV exposure… While some studies have suggested a link between severe sunburn and malignant melanoma, there are some studies that prove an inverse relationship. In a study published in the International Journal of Cancer, Canadian researchers found a significant inverse association between chronic or long-term occupational exposure in men, with the lowest risk in those with maximum occupational exposure.”
“This suggests that repeated exposure may be protective,” the FAQ continues. “Gradual, moderate exposure is not believed to be a strong influential factor, as melanoma generally develops in areas not normally exposed to UV light.”
Two issues with those statements:
1) Sunny South Carolina has the fourth highest number of U.S. melanoma deaths for men, likely from working outdoors, according to the Centers for Disease Control and Prevention; and 2) Many, or most, indoor tanners tan nude, getting UV rays where “the sun don’t shine,” precisely where melanoma strikes.
Illuminating Research, or Vitamin D Hyperbole?
Newly released studies give the tanning industry new ammo to fire back at the medical establishment’s assault: UV exposure makes the skin produce vitamin D, which helps prevent breast cancer, colon cancer and other diseases.
In the ITA’s own FAQ document, in answer to the question whether moderate exposure to UV light good for your health, the answer: “Absolutely. There is a mountain of well-conducted, validated science that demonstrates that the production of the activated form of vitamin D is one of the most effective ways the body controls abnormal cell growth. Moderate exposure to sunlight is the only way for the body manufacture the vitamin D which is necessary for the body to produce activated vitamin D.”
While quick to qualify any statement about tanning’s health advantages, the ITA’s Overstreet says there’s a “growing group of scientists, researchers and doctors who are changing their whole opinions about UV radiation.”
“I wouldn’t say there are health advantages to indoor tanning per se, but to moderate exposure to indoor light,” Overstreet says. “There’s been a lot of exciting research that has come to light - pun intended - in the last few years, to moderate exposure, and some interesting articles in the last year or two on what it can do for the body. For the last 20 to 30 years, there’s been a relentless and successful campaign to keep us out of the sun, when a lot of people are vitamin D deficient from not getting enough sun.”
Overstreet points out that Vitamin D, along with enabling the bones to absorb calcium, fends off osteoporosis and menopause in aging women, and while the sun may have links to skin cancer, “it has the exact opposite effect in inhibiting other forms of cancer.”
Overstreet is referring to a few studies in the past two years, seized on by his industry, echoed by its followers and promoters, and attracting the attention of some in the mainstream press as a “man bites dog” story. “Can Sunshine Help Prevent Cancer?” and “Research on Vitamin D Makes Doctors Consider Prescribing Sunshine” read headlines to a widely-circulated AP story.
“Scientists are excited about a vitamin again,” writes AP Medical Writer Marilyn Marchione. “But unlike fads that sizzled and fizzled, the evidence this time is strong and keeps growing.”
The story was prompted by a study describing how Vitamin D is hard to get from food and fortified milk alone, by Dr. Michael Holick, who explained how moderate exposure to sunlight is the only way for the body to manufacture activated vitamin D. Holick describes how the suns angles during winter don’t enable enough sun absorption, particularly in northerly latitudes.
Holick followed his study with a book, The UV Advantage, urging people to get enough sunlight to make vitamin D. Holick sites research that vitamin D is important for preventing and even treating many types of cancer, such as colon cancer, lymphoma and cancers of the prostate and lung.
While repeated sunburns - especially in childhood and among redheads and very fair-skinned people - have been linked to melanoma, there is no credible scientific evidence that moderate sun exposure causes it, Holick contends.
“I am advocating common sense,” not prolonged sunbathing or tanning salons, Holick says. “The problem has been that the American Academy of Dermatology has been unchallenged for 20 years. They have brainwashed the public at every level.”
After publishing the UV Advantage book, Holick’s department head, Boston University’s Dr. Barbara Gilchrest, called it an embarrassment and stripped him of his post as a dermatology professor at the speed of light (though he retained his position chief of endocrinology, nutrition and diabetes).
Holick’s study was funded by none other than the ITA and Wolff System Technology.
Still, some back up the claims. At last April’s American Association for Cancer Research meeting in Anaheim, Calif., Dr. Edward Giovannucci, a Harvard University professor of medicine and nutrition, gave a lecture in which he said his research suggests that vitamin D might help prevent 30 deaths for each one caused by skin cancer.
“I would challenge anyone to find an area or nutrient or any factor that has such consistent anti-cancer benefits as vitamin D,” Giovannucci told the cancer scientists.
Some of the vitamin D scientific advocates believe that “safe sun” - 15 minutes or so a few times a week without sunscreen - is helpful to health. But Westmoreland describes Holick’s vitamin D claims in simple, restrained language: “Bunk.”
Westmoreland and other physicians point out we get more than enough vitamin D from diet. Milk and even orange juice is routinely fortified with Vitamin D, and vitamin D occurs naturally in salmon, tuna and other oily fish.
“The amount of vitamin D you need from the sun is five minutes a week on your face, hands and forearms,” Westmoreland says. “And when they say you shouldn’t wear sunscreen, that’s ludicrous and blown completely out of proportion. You get enough of the sun’s Vitamin D from incidental living. If you’ve gone out to the grocery store and walk from your car, you’ve got it.”
Besides, adds Miller, tanning bulbs’ UVA rays have nothing to do with metabolizing or absorption of vitamin D.
“Even wearing sunscreen and getting some sun manufactures enough vitamin D, but their recommendation of being in the sun without sunscreen for 30 minutes is totally irresponsible,” Miller says.
“Vitamin D deficiency causes rickets, and I don’t see a severe rickets epidemic out there,” Baker adds. “The tanning industry is big business, and every five years or so you get one of these vitamin rumors causing people to use less sunscreen so they can get more sun.”
Raisin’ in the Sun
German scientist Friedrich Wolff founded indoor tanning while studying the beneficial effects of ultraviolet light on athletes. Wolff brought his technology to the United States in 1978, and the U.S. tanning industry grew dramatically from 1980 through the 1990s, having leveled off in just “the last couple of years,” says the ITA’s Overstreet. The business has mushroomed to $5 billion a year from $3 billion over the past five years, with 25,000 facilities nationwide, employing 160,000 and catering to nearly 30 million customers a year, the ITA reports. South Carolina has about 900 of those businesses, employing 3,000, with about 560,000 customers.
“There’s a continual market, and we’ve continued to have growth throughout the years,” said Tony Williams of Recreational Factory Warehouse, a leading retailer of tanning beds to individuals. “We should carry on with that growth as more people are conscious about the health benefits of tanning.”
Williams cited the Boston University vitamin D study, and explained that tanning beds eliminate some of the sun’s UV rays in favor of “healthier” ones. “No research has ever proved the case connecting tanning beds to skin cancer,” Williams says.
In the Upstate, where you can buy a tanning bed at under $1,900, you see tanning spas connected to video stores, many beauty salons, dry cleaners, antique shops, car washes and all kinds of other businesses with no connection to beauty, but with room for a bed. And for some reason, says Williams and Overstreet, the sunny Southeast as a region sells more tanning beds both to salons and individuals.
Spas are mostly small businesses, with a few large chains like Ultra Tan and Planet Beach relatively new entrants.
“They’re everywhere - nail salons, beauty salons and businesses that have no association even with the cosmetic industry,” Van Hale says. “And there’s no way of monitoring the output of these bulbs, so it’s really dangerous. We try to get the patients educated about this, but some say they just need three times at the spa before the prom, and that it’s better than sitting out and getting a tan.”
“They should be banned, they’re dangerous, they’re increasing the risk of skin cancer and specifically increasing the risk of melanoma,” Van Hale says. “And the people that run these places know nothing about photo medicine. There’s no cookbook and little instructions on these types of things.”
The ITA’s Overstreet sees it differently, a small business on every corner, “our little slice of Americana.”
“They’re just another way to attract customers into strip malls, where they can catch people on the way the grocery store, get gas, so they work well with video stores,” Overstreet says. “People just don’t have the leisure time they used to get a little color and look and feel good.”
Caveat Emptor: Let the Fryer Beware
The FDA regulates the manufacture and importation of indoor tanning equipment as medical devices, requiring warning labels are on the equipment, and that timers are functioning and bulbs are FDA-compliant. Also, 27 states have adopted regulations for indoor tanning salons.
“Though we sponsor laws, they’ve been a total failure due to lack of implementation,” Franzblau says. “The only way to deal with the issue is that the FDA should forbid the use of artificial UVA except for medical purposes. Regulations can’t make tanning safe. Banning salons is the only answer.”
Tanning beds are unique, says Franzblau, because unlike all other medical devices overseen by the FDA, they’re tested neither for safety nor efficacy.
Franzblau was instrumental in helping pass California’s 1988 implementing law regulating tanning spas. But the law had no mechanism for registration of tanning parlors or collection of fees from the owners. “Hence, there is no enforcement,” Franzblau says.
Franzblau now calls his work on California’s bill, “a waste of time,” because the state never implemented an enforcement system, a nationwide problem.
Only three states, Arizona, Illinois and Rhode Island, require that tanning spa operators be licensed.
Spas Operating in the Dark
Some states require salons to provide UV-protective eyewear or have machine operators remain present throughout a client’s session. Others require a sign on the booth warning people who always sunburn that tanning puts them at high risk for skin damage. Whatever the regulations, says Dr. Franzblau, there’s no assurance they will be complied with.
“I’ve taken teams of scientists into salons where not one requirement was being followed,” Franzblau says. “Governments give enforcement a very low priority and don’t think of spa tanning as potentially dangerous, while the EPA has stated openly that all UV is a carcinogen.”
There is no federal legislation being considered in Congress regulating the tanning industry, and though in 2004 there was an effort to make it illegal for those under the age of 14 to use tanning spas, that’s a “non-existent part of the business,” Overstreet says.
In May, California passed a law preventing anyone under 14 from using a tanning machine with UV rays without a doctor’s prescription. South Carolina regulations require tanning salons to get parental consent from minors who use their services.
South Carolina passed a law in 1986 providing for DHEC tanning regs, revising them in 2000 to require formal training of salon operators (five hours) and annual inspections. DHEC requires the operator to make a skin evaluation, requires that clients sign a questionnaire with disclosures about dangers of radiation and that salons keep a written “exposure schedule” available for DHEC inspection.
The training is “face-to-face,” says Charles Ditmer, DHEC section manager of the X-Ray and Radiation Inspections and Calibrations Lab. Two companies, Mann UV Technology and The International Smart Tan Network are accepted to train operators. Salons can’t state or imply in any ads or signs that the facility is approved by DHEC, can’t use the word “safe” or wording implying that the tanning equipment is free of hazards. (“No burning,” “no harmful rays,” “no adverse effects,” “healthy” cannot be used.)
Ditmer added that no such claims could be made by any employee verbally.
As for whether tanning beds are safe, Ditmer says, “without scientific documentation, which we haven’t seen, they can’t represent it in that manner.”
“No person, in any advertisement or posting, shall claim any medical or health benefits from such person’s tanning equipment, nor imply use as a medical device or treatment,” DHEC’s regs read. “You must warn customers that tanning indoors and outdoors in the same day, tanning at multiple salons, or other similar occurrences, are hazardous to their health.”
But one young woman with an interest in tanning who made random calls to 10 local tanning salons with questions about risks received answers such as “Once you tan, you won’t get burned,” and when she asked of cancer risks, an owner replied, “Oh no, it’s perfectly safe,” because you control your amount of sun. Asked why she’d heard the opposite, an operator replied, “They’re just doctors trying to find excuses to make money.”
Most operators were more careful with claims, though each said it was safe to tan every 24 hours. Most implied the safety aspect of “controlled exposure.”
One operator, explaining that any UV rays could hurt the skin, explained that even with a tan, “you could get burned on a shady day,” but indoor tanning is preferable to outdoors where you can “fall asleep and get totally fried.” Another equated indoor tanning to a concentrated dose of sun from lying out on a sunny day, but the operator couldn’t guarantee she wouldn’t be sunburned. “Yes, it my cause cancer,” was the operator’s answer. Another admitted, “Any kind of tanning is probably considered bad.”
DHEC’s regulations require operators to “recognize and report any injuries related to UV radiation,” which Ditmer explained to mean, “Even if a client reports a slight burn to an operator, they have an obligation report it to us.”
But Ditmer couldn’t say how many reports the unit has received. He said DHEC has taken enforcement actions against salons, but couldn’t name a specific incidence, or what the nature of the enforcement action DHEC takes, referring us to public affairs. Ditmer, head of DHEC’s tanning section, also said he didn’t know how many tanning salon inspectors DHEC has for the state.
In DHEC’s 1997 Annual Accountability Report, the agency set aside $139,000 “to minimize the adverse health effects from using indoor tanning devices,” including sunburn, cataracts, retinal burns, destruction of the connective layer of the skin, and skin cancer - especially melanoma. It was ranked as DHEC’s 26th top priority program (of 27, with rape violence prevention last).
The program inspected 722 of 866 facilities and 1,892 of 2,558 devices that year, and checked if operators of tanning equipment are knowledgeable about the operation of the equipment and the biological effects of ultraviolet radiation.
In DHEC’s latest Accountability Report, however, there was no mention of tanning facilities whatsoever as a priority of expenditure in the Department of Health and Environmental Control, Bureau of Radiological Health’s $1.2 million budget.
Alternatives to Nuclear Tanning
Baker and others suggests self-tanning sprays as an alternative to any tanning, because “sunlight’s relationship has been worked out to the molecule in causing basal cell carcinoma and squamous cell carcinoma.”
“The direct link between sun exposure and melanoma isn’t as well-established, but there does seem to be a link to a large amount of exposure early in life,” Baker says. “Bad sunburns early on are important links to melanoma, and have been shown in studies of children in Canada and Australia forming a higher number of moles than those who did not get as much earlier exposure.”
“The facts are out there, and the public hopefully will change its habits and advocacy groups will get the word out to high school kids,” Baker says. “In Australia, with the highest skin cancer rate in the world, they’re teaching us how to deal with it. Children are required by law to wear hats to school, and it’s made a difference there. It’s certainly a problem here. But the real facts are hard, and people don’t want to hear them.”
“So though we don’t yet know as much about it, we all regard tanning as an injury the skin,” Baker says. “If you’re going to irradiate your skin, it doesn’t matter whether you do it by burning yourself with an acetylene torch or a match, it causes the same injury.”
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