MHOA Educational Meeting June 20, 2013 SUN SAFETY: Health Impacts of Tanning & Local Boards of Health 1.

MHOA Educational Meeting June 20, 2013 SUN SAFETY: Health Impacts of Tanning & Local Boards of Health 1

Tanning Facilities: Health Issues and Regulations Beverly E. Anderson, MPH, RS Interim Director, Radiation Control Program Bureau of Environmental Health Massachusetts Department of Public Health [email protected] Ruth M. Price, MPH, MEd, CHES Program Manager, Regional Sun Safety Program Town of Danvers, Host Organization North Shore Community Health Network [email protected] 2

Learning Objectives 1. Learn about the Regional Public Health Initiative: Sun Safety Program. 2. Understand the factors contributing to skin cancer. 3. Define UV radiation and the effects of UV exposure. 4. Gain a deeper understanding of the tanning industry and public health implications. 5. Demonstrate inspection tools, enforcement strategies and recommendations. 6. Discuss present and future indoor tanning regulations and the science behind restrictions among youth. 3

Learning Objective #1 Overview of the Regional Public Health Initiative: Sun Safety Program 4

Regional Public Health Initiative Regional public health demonstration project Purpose to strengthen the capacity of local public health to work collaboratively to provide communities with health protection, promotion and prevention efforts 3+ Year Initiative History, Funding, Concept Mapping & Needs Assessment Program Design & Structure Implementation, Outputs & Evaluation Next Steps 5

Program Funding

18 Collaborating Communities Beverly Danvers* Essex Gloucester Hamilton Ipswich Lynn Lynnfield Manchester-by-the-Sea * Fiscal Host Marblehead Nahant Peabody Salem Saugus Swampscott Topsfield Wenham Rockport 7

Concept Mapping Results Concept Mapping: A method of planning that summarizes and reflects how an entire group views a topic using different graphical displays. 1. Vulnerable Populations 2. Building Regional Capacity 3. Youth/Adolescent Issues 4. Wellness Promotion and Prevention 5. Environmental Health

Feasibility & Importance Rating: Go-Zone Chart Findings suggested: Building the capacity of the local health departments to work regionally Tackle wellness issue(s) that can be addressed across the region

Sun Safety Program: Structure & Operations Program Operations Program Manager 19/week Hosted by Town of Danvers Supervision from Danvers Pubic Health Director $50,000 Annual Budget Shared office space with Danvers Public Health Nurse Laptop, mobile phone and transportation Website Work plan NS CHN Steering Committee Sun Safety Steering Committee Sun Safety Program Manager 10

Sun Safety Program Goals 1. To reduce skin cancer/ melanoma rates on the North Shore and Cape Ann Area 1. To strengthen the capacity of local public health to work more collaboratively 11

Sun Safety Program Objectives 1. To strengthen policies and regulations regarding limiting exposure to indoor and outdoor UV (ultraviolet rays). 2. To increase educational programs and awareness regarding skin cancer prevention and detection with the outcome of reducing preventable deaths. 3. To encourage the use of proper skin protection and access to shade. 4. To promote communication and share resources among local public health departments. 12

Melanoma of Skin By Gender Males: 2004-2008 13

Melanoma of Skin By Gender Females: 2004-2008 14

Targeted Risk Groups Beach goers Boaters Fishing industry Youth at camps Outdoor sports Baseball Softball Soccer, LAX, field hockey Golfers Agricultural workers/CSA Tanning salon users Mostly white Female 15 to 45 years old Prom goers 15

Green light! Red light! Melanoma stats Conducted research Science says ban the tan 12/18 communities had tanning salons 40+ tanning salons Collaborating with industry Survey-100% Not permitting/not inspecting Conflicting views Lack of tools Inadequate training Slow down- generate consensus, support, and buy-in 16

Output: Awareness Campaigns Launched Healthy Skin is In and Protect the Skin Youre in Designed logo and taglines Developed website www.sunsafety411.orgwww.sunsafety411.org Full-color tri-fold brochure, 6-foot banner, and SPF promotional packets Developed 30 and 60 second PSAs on North Shore Radio 104.9 FM targeting: Youth/Families Men (Recreational) Indoor tanners 17

Tri-Fold Sun Safety Brochure 18

Output: Educational Trainings Conducted sun safety trainings and provided SPF product for recreational staff, coaches, and teachers Collaborated with BU School of Public Health & New England Alliance for Public Health (Local Public Health Institute) in the development of an on-line training module for tanning operators and inspectors Continue to work with MDPH Bureau of Environmental Health to design and provide Indoor UV Training for health inspectors-February 2013 and MHOA Educational Meeting-June 2013. 19

Output: Regional & Consistent Tools

Challenges and Lessons Learned Operational structure is effective and replicable 18 diverse communities Varied staffing patterns Differing resources Shared goals & develop trust Time, process, buy-in Changes in FDA regulations regarding SPF & labeling Extensive work plan Municipality purchasing structure & policies Inadequate training Importance of regional efforts to develop cohesive planning and inspectional programs, and to identify areas for state collaboration 21

Understand Factors Contributing to Skin Cancer Who is at risk? Good News/Bad News Types of skin cancer Identification of skin cancer: ABCDE Sun AWARE and Prevention Learning Objective #2 22

Skin Cancer: Did you know? Skin cancer rates are soaring Most common form of all cancers Most preventable cancer 1 in 5 Americans will develop skin cancer at some point in his/her life 90% of all skin cancers is associated with ultraviolet radiation (UV) Everyone is at risk for skin cancer regardless of skin type or color (ethnicity) 23

Facts About Skin Cancer Pre-cancerous Skin Lesions Actinic keratoses Basal Cell Carcinoma (BCC) Most common type of skin cancer Estimated 2.8 million are diagnosed/yr Squamous Cell Carcinoma (SCC) Can be serious if not caught early 700,000 cases of SCC Melanoma Most serious form of skin cancer More than 75,000 were diagnosed and 8,650 died in 2009 (ACS) 24

Rising Rates of Melanoma Most common form of cancer for young adults 25-29 years One person dies of melanoma every hour (57 minutes) 1 in 50 men/women will be diagnosed with melanoma during their lifetime From 1970 to 2009, incidence increased by 800% among young women and 400% among young men 25

Good News: Skin Cancer is Preventable Skin cancer is the most preventable type of cancer Prevent childhood sunburns Practice year-round Sun Safety: Use of Broad-Spectrum SPF 15-50, UPF clothing, hats, sunglasses Increase access to shade Reduce UV exposure Avoid tanning/indoor UV exposure Use UV index and Fitzpatrick Skin Type Scale 26

Fitzpatrick Skin Type Scale Skin TypeSkin ColorCharacteristics IWhite; very fair; red or blond hair; blue or hazel eyes; freckles Always burns, never tans IIWhite; fair; red or blond hair; blue, hazel or green eyes Usually burns, tans with difficulty IIICream white; fair with any eye or hair color; very common Sometimes mild burn, gradually tans IVBrown; typical Mediterranean skin Rarely burns, tans with ease VDark brown; Middle Eastern skin types Very rarely burns, tans very easily VIBlackNever burns, tans very easily 27

Protect Your Skin: Screening Skin cancer is almost completely curable when treated early Screening is Key Examine your skin regularly Have your skin checked annually by a health care professional Monitor your skin and see physician if your moles or freckles have any of the ABCDE signs 28

ABCDE Signs & Symptoms 29

Sun Safety: Use SunAWARE Tips 30

Define UV radiation and the effects of UV exposure UVA, UVB, and UVC Understanding role of UV in tanning Using UV Index as protective measure Tanning Physiology Behavioral Tanning Issues Tanning Psychology Learning Objective #3 31

Understanding UV Spectrum 32

Spectrum: UVA, UVB & UVC Short wavelength, high energy (40-400 nm, between X-rays and visible light), non-ionizing radiation UVA (320-400 nm) responsible for tanning by stimulating melanocytes and can penetrate through clouds & glass UVB (280-320 nm) causes sunburn, UVB needed for synthesis of vitamin D UVC (280-100 nm) blocked by ozone, used in germicidal lamps Both UVA & UVB damage skin, DNA, and increase risk for skin cancer through photochemical damage 33

Tanning Physiology Melanocytes and skin layers 34

Skin Cells Understanding Melanocyte to Melanoma 3- Minute Video 35

Tanning Physiology Electromagnetic spectrum and effects 36

UV Index from National Weather Service/EPA 37

Adverse Effects of UV Acute and long-term effects of exposure to UV include: Erythema (sunburn) Cataracts and corneal burns, photokeratitis, photoconjunctivitis Skin cancer Suppression of immune system Toughening of skin, wrinkling, loss of collagen Damage to dermal blood vessels Chemical agents and drugs may exacerbate UV effects (e.g. antibiotics) 38

Vulnerable Populations All populations are vulnerable to the effects of UV Of concern are: Immunosuppressed Young people under 35 years Misperceptions of base tan or darker skin tones Access to health care screening and treatment 39

Shedding Light on UV Radiation World Health Organization (WHO) listed UV, emitted from tanning salons, as a group 1 carcinogen, and recommends that no one use a tanning bed for cosmetic purposes (2009). US Department of Health and Human Services also declared UV a human carcinogen placing tanning beds in the same cancer-causing category as tobacco. 40

Gain a deeper understanding of the tanning industry and public health implications: Describe risks of tanning devices and its link to skin cancer Health basis for regulatory control Behavioral Factors Tanning promotion & messaging Learning Objective #4 41

Tanning Facilities linked to Skin Cancer: Research Findings Exposure to indoor tanning enhances risk for skin cancer, including melanoma by 75% (COMARE, IARC). Indoor tanners have a 69% increased risk of basal cell carcinoma 1 session increases chance of developing melanoma by 20% 4 sessions/year increases risk of BCC and SCC by 15% Risk increases with exposure to indoor tanning before age 35 and is highest based on exposure before age 18 (WHO, FDA, AADA, CDC) Cells that are changing or in transition are most vulnerable to effects of radiation. 42

Health Basis for Regulatory Control of Tanning Facilities WHO/IARC concludes from the 19 studies conducted over 25 years there is the evidence of squamous cell carcinoma and melanoma due to indoor tanning. Risk of melanoma increases by 75% among when use starts before age 35 Melanoma and all skin cancers are steadily increasing Melanoma incidence rates have climbed for past 30 years Estimated 76,250 new cases of melanoma will occur in the U.S. this year-a rise of 6,020 cases from 2011 (ACS, 2012) 43

Indoor UV Tanning Ray is Stronger UV rays from tanning beds are 12 X stronger than the sun UVA is the tanning ray which tanning beds primarily emit (95% of total) UVB is the chief cause of skin reddening and sunburn UVA and UVB penetrate deep into skin and damage DNA, contributing to development of all skin cancers UVA and UVB damages skin cells squamous cells keratinocytes in the basal cell layer of the epidermis causing basal cell carcinoma melanocytes causing melanoma 44

Indoor Tanning and Teens The skin of teens is more vulnerable because their cells are dividing and changing more rapidly than those of adults. 37% of white female adolescents and over 11% of white male adolescents between 13 and 19 years old in the US have used tanning booths within last year. Fairer skin, eyes, at highest risk for skin damage. Conclusion: Highest risk group (young, Caucasian) is also highest user group! 45

Tanning Psychology 2005 American Academy of Dermatology Survey (AAD) 95% of respondents understood that getting a tan is dangerous 65% said they think they look better with a tan. 1 out of 3 teenagers say they tan because it looks healthy An AAD survey found that more than 80% of people aged 25 and younger said they looked better with a tan. 46

Tanning & Addiction Frequent tanners show signs of both physical and psychological dependence UV light has show to increase release of opioid-like endorphins Frequent tanners report benefits of mood enhancement, relaxation and difficulty quitting use A 2006 study showed 95% of frequent tanners could distinguish between UV and non-UV light emitting tanning beds (brain activity supported this) compared with non- frequent users who could not discern 47

Indoor Tanning Statistics Approximately 30 million Americans go to tanning salons annually 70% of all users are Caucasian women, ages16-49 Use rates are increasing among males and Latinos 2.3 million US teens visited a tanning salon in last year 1 in 4 of ALL US teen girls have used indoor UV tanning devices (lifetime) 48

Tanning Industry Indoor tanning is a $5 billion- a-year industry 25,000+ tanning salons in U.S. More prevalent than McDonalds or Starbucks 600 stand alone tanning salons in MA Sun Safety region: 40+ tanning facilities in 18 communities Increasing number of tanning services in gyms and salons 49

Promotional Messages Get your vitamin D here cancer prevention Beauty look better Sun-Kissed Healthy Glow 50

Base Tan Myths Base tan provides protection equal to SPF3 Bob Marley Base tan does not protect against repeated high level of UV exposure 51

Vitamin D Role in cancer prevention Adequate from balanced diet Vitamin D can be generated from limited sun exposure-15 minutes Success of Vitamin D production from UV exposure depends on presence of substance in skin, age, etc. Relies on exposure to UVB 52

Vitamin D: Perceived Health Benefit WHO/IARC found modern sunbeds emit 0.5% UVB or less and are not recommended for increasing vitamin D levels. Synthesis of vitamin D reaches a plateau after a few sunbed sessions. Vitamin D can be supplied nutritionally. FDA has not cleared or approved any indoor tanning device for producing vitamin D. Risks outweigh benefits. 53

Demonstrate inspection tools, enforcement strategies, and recommendations. Learning Objective #5 54

Radiation Control Program Bureau of Environmental Health Statutory authority M.G.L. Chapter 111, Sec. 207-214 for tanning facilities Regulates use of specific radioactive materials in the Commonwealth Nuclear Incident Advisory Team responds to all radiation-related emergencies in Commonwealth Participate in nuclear power plant exercises Regulate x-rays, CT scans, nuclear medicine and mammography 55

Authority for Tanning Facilities 56

105 CMR 123.000 Provide minimum standards for the prevention of infectious disease transmission and prevention of serious injuries (burns, skin diseases) Do NOT prevent long-term health consequences 57

Types of Tanning Devices Tanning bed Upright unit 58

Tanning Devices Bulb type specified by manufacturers Dose derived from type of bulb (UVA:UVB) and exposure time with particular device Bulb must be appropriate for device to prevent serious injury Units differ: operating manuals and specifications for each unit essential 59

Tanning Devices Expose skin to UVA rays (but also UVB) that promote tanning. Bulbs created to promote these tanning rays. High pressure lamps provide more UVA rays, less UVB (pressure refers to bulb type). Timing of exposure must be adjusted based on the type of lamp used in to prevent burning of skin and overexposure to UV. 60

Tanning Devices Warnings Using the incorrect type of bulb may cause serious harm through overexposure. Serious damage to eyes and vision possible with misuse of devices and lack of protective eyewear 61

Inspection Issues Check for operator knowledge-123.003 (C) www.masslocalinstitute.org Manuals should be available for all devices Check bulb guidance and usage instructions Suspend operation if hazard to health and safety present Ensure communications and warnings present 62

Requirements for Tanning Devices 123.003 (2) (a) Only tanning devices manufactured and certified to comply with the Code of Federal Regulations (b) each tanning device shall have a timer (d) there shall be physical barriers (e) Additional requirements for stand-up booths 1. there shall be physical barriers or other method (g) licensee shall maintain records of the recommended exposure time established by manufacturer of the timing device 63

Operation of Tanning Facilities: Physical Plant 123.003 (A) (1) Warning Sign (a) 3 feet of each device (b) Readily legible, clearly visible, and not obstructed (c) Printed in white on a red background (e) 8 in. wide by 11 in. long (f) DANGER 64

Protective Eyewear 123.003 (B) (1) Protective eyewear which meets the requirements of 21 CFR 1040.20(c)(4) (2) manufacturers eyewear literature (3) properly sanitized 65

Operators 123.003 (C) (1) Each operator must be trained and sufficiently knowledgeable in the correct operation of tanning devices used at a facility (b) proper use of U.S.F.D.A. Recommended Exposure Schedule (c) photosensitizing agents: foods, Rx, cosmetics (d) skin type determination (Fitzpatrick) (i) effects of UV radiation (2) A list of the facilitys (trained) operators (3) A trained operatorat all times! 66

Records 123.003 (D) (1) Each time a customer uses a tanning facility, or each time a customer executes or renews a contract to use a tanning facility (2) No person 14 years of age to 17 years of agewithout prior written consent of a parent or legal guardianwho has read and understood the warnings (3) No person under 14 years of age shall use a tanning device unless accompanied by a parent (4) A record shall be kept by the operator of each customers total number of tanning visitsfor at least 12 months 67

Injury Reports 123.003(E) (1) A written report of any tanning injury to a customer or complaint of injury shall be forwardedto the Board which issued the license and to the Department with a copy to the complainantwithin five working days 68

Sanitation 123.003 (F) (1) The operator shall provide to customersaccess to toilet and hand washing facilities (a) cleaned and disinfected every 24 hours (b) contain liquid soap, paper towels and a receptacle (2) Each customer shall have access to a safe and sanitary supply of drinking water (3) Each facility shall provide paper or cloth towels which may not be shared (4) All surfacesshall be disinfected after each customers useusing an U.S.E.P.A. registered disinfectant 69

Inspections 123.004 (A) The Board of Health shall inspect each tanning facility within 30 days of licensure, every six months thereafter (B) The BOH shall have access at all reasonable times to any tanning facility for the purpose of inspecting 70

Promotional Claims 123.003 (G) No tanning facility shall claim, or distribute promotional material that claims that the use of a tanning device is safe and free from risk. 71

Permit Application Critical to match # of reported devices and details with # of inspected devices during site visit. 72

Inspection Tool 73 123.003 G No material or promotional item that claims use of tanning is safe and free from risk.

Regulatory Issues: Present and Future Highlight global and local changes in legislation and access to tanning. Discuss direction of indoor tanning regulations and restrictions. Learning Objective #6 74

Proposed Legislation and Recommendations WHO, AADA, CDC recommendations on age limits Britain and Brazil banned California, Vermont, New Jersey, Nevada and city of Chicago uses science to prohibit minors from indoor tanning devices Proposed MA Legislation, Senate 2211, proposed age limits MDPH Office of General Counsel discussion Local regulation change restricting access 75

WHO Calls for Restrictions Among Youth & Sunbeds As long as sunbeds are available to the public, there is a need for guidelines or legislation to reduce the risks associated with their use. WHO encourages governments to formulate and enforce effective laws governing the use of sunbeds. Of highest regulatory priority should be the restriction of use by persons under 18 years as well as banning unsupervised trained personnel. WHO recommendations are consistent with those of the International Commission on Non-Ionizing Radiation Protection (ICNIRP) and the European Society for Skin Cancer Prevention (EUROSKIN). 76

Dermatologists Say No to Minors The American Academy of Dermatology Association (AADA) opposes indoor tanning and supports a ban on the production and sale of indoor tanning equipment for non-medical purposes. The American Academy of Dermatology supports the WHO recommendation that minors should not use indoor tanning equipment because indoor tanning devices emit UVA and UVB radiation, and because overexposure to UV radiation can lead to the development of skin cancer. 77

Warning from U.S. Food & Drug Administration The FDA wants consumers to know that UV radiation in tanning devices poses serious health risks. A recent report by the International Agency for Research on Cancer, (IARC), part of the World Health Organization, concludes that tanning devices are more dangerous than previously thought. Exposure to UV radiation, whether from the sun or indoor tanning beds, can cause: Skin cancer Skin burns Premature skin aging Eye damage (both short- and long-term) 78

Physicians Support Policy Change 79 Recommendations in the United States for improved sun protection and avoidance of tanning beds and sunburning, which began in the early 1990s, have been primarily unheeded. Nationally coordinated campaigns with strong policy components must be developed and sustained to prevent skin cancer in a new generation of children and adolescents. (Pediatrics, Vol 109) American Academy of Pediatrics (AAP), a group of 60,000 pediatricians

Proposed Age Restrictions in MA Bill S.1105 An act further regulating tanning facilities by James E. Timilty, et. al. Referred to Joint Committee on Public Health Section 211. No person under the age of 18 shall use a tanning device. 80

Proposed FDA Labeling May 6, 2013: FDA issued a proposal to increase consumer awareness of tanning bed risks. The order would reclassify sunlamp products from a low risk device (class I) to a moderate risk device (class II). Using indoor tanning beds can damage your skin and increase your risk of developing skin cancer, said FDA Commissioner Margaret A. Hamburg, M.D. The FDAs proposed changes will help address some of the risks associated with sunlamp products and provide consumers with clear and consistent information. The proposed order does not prohibit the use of sunlamp products by those under the age of 18, but it provides a warning on the consequences. Commentary welcome for 90 days until August 2013 81

Suggested BOH Options for Changes to 105 CMR 123.000 Improve enforcement Refer advertising on Vitamin D claim to Attorney Generals office Require proof of customer age in records (ID, license) Require proof of adequate operator training Age restrictions-under 18 years Ban on tanning facilities or phase-out Communications from tanning industry Refine message under 105 CMR 123.003(G) Develop more disease- based messages Eliminate claims to Vit D, base tan Imposition of fines Work with Town Counsel to develop regulatory changes 82

MDPH Legal Analysis of Regs Question Can a local BOH develop regulations more restrictive than State regulations for indoor tanning? 83 Answer Almost certainly yes. Case law from MA Supreme Judicial Court holds that reasonable health regulations passed by local boards of health are valid unless they are in sharp conflict with state laws

Sun Safety Program: Next Steps To capitalize on the growing momentum of local, statewide and national policy of reducing access to indoor tanning among minors, under age 18 years. To work specifically with each unique municipality in strengthening policies and regulations regarding the use of tanning beds. Strengthen policy among local boards to reduce access among minors and indoor tanning through education, awareness efforts and enforcement practices. Continue to work with MDPH General Counsel to develop language and provide guidance to Local Boards of Health. 84

Tanning: Select Your Cancer? 85

Questions and Discussion 86

Helpful Resources FDA www.fda.govwww.fda.gov CDC Skin Cancer www.cdc.gov www.cdc.gov EPA SunWise www.epa.gov/sunwise www.epa.gov/sunwise WHO/IARC www.who.int/topics www.sunsafety411.org American Cancer Society www.cancer.org www.cancer.org Health Physics Society www.hps.org www.hps.org Massachusetts Melanoma Foundation American Academy of Dermatology Skin Cancer Foundation www.skincancer.org www.skincancer.org MA Local Public Health Institute 87

References & Resources 2003 World Health Organization, Artificial Tanning Sunbeds Risks and Guidance 2006 IARC, World Health Organization, International Agency for Research on Cancer, Exposure to Artificial UV Radiation and Skin Cancer QuickStats. MMWR, October 13, 2006. 55(40):1101QuickStats The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. International Journal of Cancer. 2007. 120(5): 1116-1122. UV light abuse and high-risk tanning behavior among undergraduate college students. Poorsattar, S.P. and Hornung, R.L. J. American Academy of Dermatology, 2007. 56(3): 375-379. Guidelines for School Programs to Prevent Skin Cancer. MMWR. 2002. 51(RR04): 1-16. CDC, WHO, AADA, AAP, MDPH, FDA, EPA, ACS, Skin Cancer Foundation 88

MHOA Educational Meeting June 20, 2013 SUN SAFETY: Health Impacts of Tanning & Local Boards of Health 1.

Documents

environmental health

health issues

health protection

public health implications

program funding slide

safety program manager

safety program objectives

safety program goals