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  • The early indoor tanning beds in the US emitted high levels of UVB which caused sunburn, skin disorders and many other health effects.
    1970’s: supposedly reducing health risks such as sunburn.
  • 25% of the 70% includes appearance-conscious young age group of 16-24.
    This explains why the primary goal of WHO’s current effort is to protect these teens and young adults. WHO places its empahsis on stricter governments to formulate and reinforce laws to control the use of tanning operations.
    The acknowledged health threat of artificial tanning holds no significance in the lives of many Americans.
  • Like the sun, sunlamps give off 2 types of radiation UVA and UVB. The types are separated into categories based on wavelengths. UVA has a longer wavelength of 320-400nm and UVB has a shorter wavelength of 290-320nm. Both UV wavelengths have harmful effects
    UVB is the most destructive form of UV because it has enough energy to cause photochemical damage to cellular DNA.
    UVB effects can include erythema (sunburn), cataracts, and the development of skin cancer.
    UVA: Most commonly encountered type of UVR in sunbeds. Though once thought to be relatively safe due to the low energy production, Overexposure of UVA has been shown to cause toughening of the skin or aging, suppression of the immune system, and cataract formation.
  • This is when people go to tanning beds to prepare their skin for a sunny vacation. It only leads to extra radiation during the prevacation period and leads to decreased use of sun-protective precautions during vacation. In addition it affords practically no photoprotection.
    Psychosocial motivation of appearance and physiologic stimulus of relaxation are compromised for one’s health risk.
    This concept of the potential addictive factor reveals the importance of educating youth and steering the younger generations clear from indoor tanning
  • This explains why most experience sunburns on their face. Positioning in the tanning bed also plays a role.
  • FDA mandates that eye protection must be worn- but go and visit some of these salons and you’ll find you often have to purchase the eyewear and most operators do not enforce eye protection
    Phototoxic reactions result from direct damage to tissue caused by light activation of the photosensitising agent, whilst photoallergic reactions are a cell mediated immune response in which the antigen is the light-activated photosensitising agent.
    Photoallergic reactions are mostly caused by photosensitising topical agents, whereas photoxic reaction soften occur due to ingestion of medications.
    Although some oral photosensitising medications can cause photoallergic reactions, most cause phototoxic reactions.
    A handful of medications can cause both phototoxic and photoallergic reactions.
  • Due to chronic exposure to UV
    The issue occurs most often later in life, with the younger population being blinded to the delayed effect of chronic sun exposure.
    Imagine the doubling of effects placed on the skin when photo aging and natural aging are coexistent.
  • accounting for almost ½ of all CA’s in U.S.
    NCI : 40-50% of Americans who live to the age of 65 will have non-melanoma skin cancer at least once
  • BCC:long-term or intense intermittent
    SCC: (total cumulative lifetime); Ability to metastasize
  • FDA requirements on lamp specifications, posting of warning labels, & provision of suitable eye protection
    Federal Trade Commission: investigates deceptive and false advertising (Claims indoor tanning is safe)
    The FDA’s website does state that they do not recommend the use of indoor tanning equipment ever due to the associated aging and cancer
  • THE MED: the suggested time posted on the device that a person be exposed to artificial UV based on skin type and previous visits.
    This is a major factor leading to the health risks because tanning salon operators are not enforcing the recommended MED proposed by manufacturers.
  • The protocol was intended to lead to the development of tanning exposure guidelines that, if followed, should provide indoor tanning with the lowest risk for long-term effects.
    Government regulation of indoor tanning is insufficient and hampered by lobbying of the indoor tanning industry.
  • When educating about drug usage and sexual activity, include sun protection.
    2 decades of public health campaigns in Australia have led to a large shift in knowledge and beliefs about sunlight exposure and behavior.
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    1. 1. The Darker Side of Indoor Tanning Author: Lauren Alderdice Advisor: Professor VanDyke
    2. 2. History of Indoor TanningHistory of Indoor Tanning  1906: Medical company in Germany made the1906: Medical company in Germany made the worlds 1worlds 1stst indoor UV tanning bed used to treatindoor UV tanning bed used to treat rickettsricketts  11stst generation of indoor tanning beds weregeneration of indoor tanning beds were principally UVB emitting; plagued by manyprincipally UVB emitting; plagued by many safety problemssafety problems  1970’s: Development of high intensity UVA light1970’s: Development of high intensity UVA light sources for medical purposes; was quicklysources for medical purposes; was quickly followed by their use in commercial tanningfollowed by their use in commercial tanning parlorsparlors
    3. 3. Indoor Tanning StatisticsIndoor Tanning Statistics  30 Million Americans visit indoor tanning salons30 Million Americans visit indoor tanning salons each yeareach year  70% are Caucasian girls and women between the70% are Caucasian girls and women between the ages of 16 and 49ages of 16 and 49  2005 AAD survey: 92% of respondents2005 AAD survey: 92% of respondents understood that getting a tan from the sun isunderstood that getting a tan from the sun is dangerous; Yet, 65% said they think they lookdangerous; Yet, 65% said they think they look better when they are tan.better when they are tan.
    4. 4. UV Sources in Tanning BedsUV Sources in Tanning Beds  UVA: 95%, aging ofUVA: 95%, aging of the skin with recentthe skin with recent studies provingstudies proving cancer and geneticcancer and genetic damage.damage.  UVB: 5%, sunburnsUVB: 5%, sunburns and skin cancerand skin cancer
    5. 5. Reasons for tanningReasons for tanning  Recurrent themes :to look good ,relaxation, and toRecurrent themes :to look good ,relaxation, and to prepare for a special event. (Murray and Turner’sprepare for a special event. (Murray and Turner’s qualitative study)qualitative study)  Prevacation Tan- SPF 3Prevacation Tan- SPF 3  Zeller et al. :more difficult to quit tanning at youngerZeller et al. :more difficult to quit tanning at younger ages and higher frequency of use due to the mood-ages and higher frequency of use due to the mood- enhancing or relaxing effects.enhancing or relaxing effects.  Feldmen, et al. study :artificial UVR is a reinforcingFeldmen, et al. study :artificial UVR is a reinforcing stimulus in frequent indoor tanners.stimulus in frequent indoor tanners.
    6. 6. Adverse Effects of SunbedsAdverse Effects of Sunbeds  Sunburn: most apparent acute adverse effectSunburn: most apparent acute adverse effect  Determinants: Thickness of skin, skinDeterminants: Thickness of skin, skin pigmentation based on hereditary skin type &pigmentation based on hereditary skin type & exposure timeexposure time  CDC :700 visits were made to ED in a single yearCDC :700 visits were made to ED in a single year due to tanning bed burnsdue to tanning bed burns  AAD reports in Italy: 25% of sunbed usersAAD reports in Italy: 25% of sunbed users experience sunburns in devices, but only 60%experience sunburns in devices, but only 60% suspend sessions after burning.suspend sessions after burning.  Blistering sunburns (even only a few) 1Blistering sunburns (even only a few) 1stst 18 yrs of18 yrs of life significantly increase the risk for MMlife significantly increase the risk for MM
    7. 7. Other Immediate EffectsOther Immediate Effects  Ocular disorders: cornealOcular disorders: corneal burns, cataracts, &burns, cataracts, & permanent eye damagepermanent eye damage  CDC : 152 pts had beenCDC : 152 pts had been treated for eye injuries intreated for eye injuries in a 12 month period relateda 12 month period related to tanning devicesto tanning devices  Phototoxic/ PhotoallergicPhototoxic/ Photoallergic Rxns include but are notRxns include but are not limited to: NSAIDS,limited to: NSAIDS, Diuretics, ABX, TCA’sDiuretics, ABX, TCA’s
    8. 8. Chronic Adverse EffectsChronic Adverse Effects  PhotoagingPhotoaging  Common in middle-Common in middle- aged, and elderlyaged, and elderly whiteswhites  Coarse, roughened,Coarse, roughened, deeply wrinkled skin,deeply wrinkled skin, reductions inreductions in elasticity and recoilelasticity and recoil
    9. 9. Indoor Tanning & Skin CancerIndoor Tanning & Skin Cancer  UV exposure : mostUV exposure : most important environmentalimportant environmental factor in developmentfactor in development  Most common CA in U.S.Most common CA in U.S.  Increasing in prevalenceIncreasing in prevalence  ACS : “ Exposure toACS : “ Exposure to sunlight causes almost allsunlight causes almost all cases of basal andcases of basal and squamous cell skin cancersquamous cell skin cancer and is a major cause ofand is a major cause of skin melanoma”skin melanoma”
    10. 10. Skin CA Cont.Skin CA Cont.  BCC: 80%; Cumulative sunBCC: 80%; Cumulative sun exposure is main risk factorexposure is main risk factor  SCC: 2SCC: 2ndnd most common; Excessmost common; Excess UV exposureUV exposure  MM: Most fatal; excessive sunMM: Most fatal; excessive sun exposure (esp. sunburn) mostexposure (esp. sunburn) most preventable causepreventable cause  NCI: Women who use tanningNCI: Women who use tanning beds>1/mo are 55% morebeds>1/mo are 55% more likely to develop MMlikely to develop MM  IARC: 1IARC: 1stst exposure to sunbedsexposure to sunbeds before 35 yoa significantlybefore 35 yoa significantly increases the risk of MMincreases the risk of MM
    11. 11. How Indoor Tanning Is RegulatedHow Indoor Tanning Is Regulated  FDAFDA  FTCFTC  Operators of indoorOperators of indoor tanning: state level ortanning: state level or not at allnot at all
    12. 12. Pitfalls of EnforcementPitfalls of Enforcement  FDA ONLY recommends maximum exposure dosagesFDA ONLY recommends maximum exposure dosages  Survey of tanning facilities in NC :95% of patronsSurvey of tanning facilities in NC :95% of patrons exceeded recommended limits, with 33% beginning atexceeded recommended limits, with 33% beginning at maximum doses recommended for maintenance tanningmaximum doses recommended for maintenance tanning  FDA DOES NOT regulate the proportion of UVA andFDA DOES NOT regulate the proportion of UVA and UVB emittedUVB emitted  FDA Center for Devices and Radiological Health hasFDA Center for Devices and Radiological Health has shown that on a per-MED basis: UVA doses of 1.1 to 4.1shown that on a per-MED basis: UVA doses of 1.1 to 4.1 times that of the sun are used in regular tanning lampstimes that of the sun are used in regular tanning lamps and doses of 10 to 15 times that of the sun in newlyand doses of 10 to 15 times that of the sun in newly available high-pressure sunlamps.available high-pressure sunlamps.
    13. 13. Government PositionGovernment Position  Contends with the strongContends with the strong lobbying at federal andlobbying at federal and state levels by thestate levels by the multibillion-dollarmultibillion-dollar tanning industry.tanning industry.  2003: FDA developed2003: FDA developed amendment proposals toamendment proposals to develop a safer tanningdevelop a safer tanning protocol that have yet toprotocol that have yet to be put in place.be put in place.
    14. 14. Bottom LineBottom Line  Appearance is driving patrons to the readilyAppearance is driving patrons to the readily accessible artificial UVR devicesaccessible artificial UVR devices  http://www.youtube.com/watch?v=b2oyYUhl0Uhttp://www.youtube.com/watch?v=b2oyYUhl0U
    15. 15. The Role of PA’sThe Role of PA’s  Increase efforts to warn and educate the publicIncrease efforts to warn and educate the public and government about the dangers of excessiveand government about the dangers of excessive UV exposureUV exposure  Incorporate patient education on artificialIncorporate patient education on artificial tanning in our daily practicestanning in our daily practices  Sports physical for adolescents: 5Sports physical for adolescents: 5thth Vital SignVital Sign  Evidence that prevention efforts can be effectiveEvidence that prevention efforts can be effective over timeover time
    16. 16. ReferencesReferences  Albert MR, Ostheimer KG. The evolution of current medical and popular attitudes toward ultraviolet light exposure: part 3. J Am Acad Dermatol. 2003 Dec; 49(6):1096-Albert MR, Ostheimer KG. The evolution of current medical and popular attitudes toward ultraviolet light exposure: part 3. J Am Acad Dermatol. 2003 Dec; 49(6):1096- 1106.1106.  American Academy of Dermatology (AAD). Skin Cancer. 2005. Available atAmerican Academy of Dermatology (AAD). Skin Cancer. 2005. Available at http://http://www.aad.org/public/Publications/pamphlets/SkinCancer.htmwww.aad.org/public/Publications/pamphlets/SkinCancer.htm  American Academy of Dermatology (AAD). 2006 Skin Cancer Fact Sheet. Available atAmerican Academy of Dermatology (AAD). 2006 Skin Cancer Fact Sheet. Available at  http://www.aad.org/aad/Newsroom/2005+Skin+Cancer+Fact+Sheet.htmhttp://www.aad.org/aad/Newsroom/2005+Skin+Cancer+Fact+Sheet.htm  Amercian Cancer Society. Cancer Facts and Figures 2005. Available atAmercian Cancer Society. Cancer Facts and Figures 2005. Available at http://http://www.cancer.orgwww.cancer.org  Centers for Disease Control and Prevention (CDC). Epidemiologic Notes and Reports Injuries Associated with Ultraviolet Tanning Devices – Wisconsin. Morbidity andCenters for Disease Control and Prevention (CDC). Epidemiologic Notes and Reports Injuries Associated with Ultraviolet Tanning Devices – Wisconsin. Morbidity and Mortality Weekly Report. 1989 May;Mortality Weekly Report. 1989 May; 38(19):333-335.38(19):333-335.  Demko CA, Borawski EA, Debanne SM, Cooper KD, Stange KC. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc. 2003;Demko CA, Borawski EA, Debanne SM, Cooper KD, Stange KC. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc. 2003; 157: 854-860.157: 854-860.  Feldman SR, Liguori A, Kucenic M, Rapp SR, Fleischer Jr. AB, Lang W, et al.Feldman SR, Liguori A, Kucenic M, Rapp SR, Fleischer Jr. AB, Lang W, et al.  Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol. 2004; 51(1):45-51.Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol. 2004; 51(1):45-51.  Ferguson, J. WHO says skin cancer incidence is rising. Journal Watch Dermatology. 2005;4 (4).Ferguson, J. WHO says skin cancer incidence is rising. Journal Watch Dermatology. 2005;4 (4).  Gambichler T, Breukmann F, Boms S, Altmeyer P, Kreuter A. Narrowband UVBGambichler T, Breukmann F, Boms S, Altmeyer P, Kreuter A. Narrowband UVB  phototherapy in skin conditions beyond psoriasis. J Am Acad Dermatol. 2005; 52(4):660-70.phototherapy in skin conditions beyond psoriasis. J Am Acad Dermatol. 2005; 52(4):660-70.  Gorgos D. Popularity of indoor tanning contributes to increased incidence of skin cancer. Dermatology Nursing. 2006 June; 18(3):281.Gorgos D. Popularity of indoor tanning contributes to increased incidence of skin cancer. Dermatology Nursing. 2006 June; 18(3):281.  Hillhouse JJ, Turrisi R. Examination of the efficacy of an appearance-focused intervention to reduce UV exposure. Journal of Behavioral Medicine August 2002; 25(4):Hillhouse JJ, Turrisi R. Examination of the efficacy of an appearance-focused intervention to reduce UV exposure. Journal of Behavioral Medicine August 2002; 25(4): 395-409.395-409.  Hornung RL, Magee KH, Lee WJ, Hansen LA, Hsieh Y. Tanning facility use: Are we exceeding Food and Drug Administation limits? J Am Acad Dermatol. October 2003;Hornung RL, Magee KH, Lee WJ, Hansen LA, Hsieh Y. Tanning facility use: Are we exceeding Food and Drug Administation limits? J Am Acad Dermatol. October 2003; 49(4): 655-660.49(4): 655-660.  IARC Working Group. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review. Int. J. Cancer. 2006;IARC Working Group. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review. Int. J. Cancer. 2006; 120:1116-1122.120:1116-1122.  Isaacs G, Stainer DS, Sensky TE, Moor S, Thiompson C. Phototherapy and itsIsaacs G, Stainer DS, Sensky TE, Moor S, Thiompson C. Phototherapy and its  mechanisms of action in seasonal affective disorder. J Affective Disorder. 1988; 14:13-19.mechanisms of action in seasonal affective disorder. J Affective Disorder. 1988; 14:13-19.  Knight JM, Kirincivh AN, Farmer E, Hood AF. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol. OctoberKnight JM, Kirincivh AN, Farmer E, Hood AF. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol. October 2002; 138(10):1311-11315.2002; 138(10):1311-11315.  Lee T, Chen E, Chan C, Paterson J, Janzen H, Blashko C. Seasonal affective disorder. Clinical Psychology: Science and Practice. 1998; 5(3):275-90.Lee T, Chen E, Chan C, Paterson J, Janzen H, Blashko C. Seasonal affective disorder. Clinical Psychology: Science and Practice. 1998; 5(3):275-90.  Levine JA, Sorace M, Spencer J, Siegel D. The indoor UV tanning industry: A review ofLevine JA, Sorace M, Spencer J, Siegel D. The indoor UV tanning industry: A review of  skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol.skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol.  2005; 53(6):1038-44.2005; 53(6):1038-44.  Lim HW, Cyr WH, DeFabo E, Robinson J, Weinstock MA, Beer JZ, et al. Scientific and regulatory issues related to indoor tanning. J Am Acad Dermatol. 2004; 51(5):781-Lim HW, Cyr WH, DeFabo E, Robinson J, Weinstock MA, Beer JZ, et al. Scientific and regulatory issues related to indoor tanning. J Am Acad Dermatol. 2004; 51(5):781- 4.4.  Lim HW, Gilchrest BA, Cooper KD, Bischoff-Ferrari HA, Rigel DS, Cyr WH, et al. Sunlight, tanning booths, and vitamin D. J Am Acad Dermatol. 2005; 52(5):868-76.Lim HW, Gilchrest BA, Cooper KD, Bischoff-Ferrari HA, Rigel DS, Cyr WH, et al. Sunlight, tanning booths, and vitamin D. J Am Acad Dermatol. 2005; 52(5):868-76.  MacKie R M. Long-term health risk to the skin of ultraviolet light. Progress in Biophysics and Molecular Biology. 2006; 92:92-96.MacKie R M. Long-term health risk to the skin of ultraviolet light. Progress in Biophysics and Molecular Biology. 2006; 92:92-96.  Morbidity and Mortality Weekly Report (MMWR). Quickstats: percentage of teens aged 14-17 years who used indoor tanning devices during the preceeding12 months, byMorbidity and Mortality Weekly Report (MMWR). Quickstats: percentage of teens aged 14-17 years who used indoor tanning devices during the preceeding12 months, by sex and age---United States, 2005. October 13, 2006; 55(40):1101.sex and age---United States, 2005. October 13, 2006; 55(40):1101.  Murray CD, Turner E. Health, risk and sunbed use: A qualitative study. Health, Risk and Society. March 2004; 6(1): 67-80.Murray CD, Turner E. Health, risk and sunbed use: A qualitative study. Health, Risk and Society. March 2004; 6(1): 67-80.  National Cancer Institute (NCI). Artificial Tanning Booths and Cancer. 2004. Available atNational Cancer Institute (NCI). Artificial Tanning Booths and Cancer. 2004. Available at http://http://www.cancer.govwww.cancer.gov  Neale, RE, Davis M, Pandeya N, Whiteman DC, Green AC. Basal cell carcinoma on the trunk is associated with excessive sun exposure. J Am Acad Dermatol. In press,Neale, RE, Davis M, Pandeya N, Whiteman DC, Green AC. Basal cell carcinoma on the trunk is associated with excessive sun exposure. J Am Acad Dermatol. In press, Corrected proof, Available online 13 October 2006.Corrected proof, Available online 13 October 2006.  Palmer RC, Mayer JA, Woodruff SI, Eckhardt L, Sallis JF. Indoor tanning facility density in eighty U.S. cities. J. of Community Health. 2002; 27(3):191-202.Palmer RC, Mayer JA, Woodruff SI, Eckhardt L, Sallis JF. Indoor tanning facility density in eighty U.S. cities. J. of Community Health. 2002; 27(3):191-202.  Rhainds M, De Guire L, Claveau J. A population based survey on the use of artificial tanning devices in the Province of Quebec, Canada. J Am Acad Dermatol. 1999 Apr;Rhainds M, De Guire L, Claveau J. A population based survey on the use of artificial tanning devices in the Province of Quebec, Canada. J Am Acad Dermatol. 1999 Apr; 40(4): 572-6.40(4): 572-6.  Sinclair, C. Risks and benefits of sun exposure: implications for public health practice based on the Australian experience. Progress in Biophysica and Molecular Biology.Sinclair, C. Risks and benefits of sun exposure: implications for public health practice based on the Australian experience. Progress in Biophysica and Molecular Biology. 2006;92: 173-178.2006;92: 173-178.
    17. 17. Questions?Questions?

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