The role of policy-related and environmental factors in influencing individual health behavior has gained considerable attention. Although there has been some effort in quantifying state laws and relating them to outcomes, particularly for tobacco control and minors’ access to tobacco, little work has been done in the area of indoor tanning legislation. Macrolevel ecologic variables, such as state laws, may directly or indirectly impact indoor tanning behavior and health status.
We developed and applied a 35-item instrument to quantify and characterize the stringency of state laws regulating indoor tanning, with an emphasis on minors’ access. The instrument appears to be easy to use with little training, and can be applied by individuals who have no specific training in the law or in indoor tanning policy. Interrater reliability (eg, between two untrained independent senior-level health researchers) was good to excellent on most items. Nine stringency subscales and an overall stringency scale were computed to evaluate different content areas of indoor tanning legislation, including minors’ access. The stringency measures generally showed good internal consistency and interrater reliability. In addition, the validity of the instrument was supportede—a model law received a significantly higher overall stringency score than did typical, actual laws. There was variability in the states’ stringency scores and no range effects, indicating sensitivity of the instrument, and its use for showing changes over time.
A few items, including one assessing age limits for minors’ use, showed poor interrater reliability. Furthermore, the internal consistency of the minors’ access subscale was relatively low, indicating heterogeneous items. Indoor tanning among teenagers is a public health issue that is likely to receive more attention in the future. Therefore, a reliable methodology for evaluating ordinances regulating teen use is essential. Recently, we collected feedback from the independent raters about the few problem items on our instrument, and we will continue to refine them.
Application of the instrument to actual laws showed that, in general, state laws are much weaker than they could be, although there was considerable variability by state. The laws of Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island were the most stringent overall. Those of Texas and New Hampshire were the most stringent regarding minors’ use. Comparison of our results with other studies is difficult because most other studies have focused on compliance
Our results are somewhat consistent with reports from Francis et al21
that Texas, Illinois, Wisconsin, California, North Carolina, and New Hampshire have relatively strict youth access laws (ie, minimum age limits). Even among the current study’s “best” states, however, there is room for improving specific domains of indoor tanning legislation. Furthermore, given the fact that only 28 of the states have any law regulating indoor tanning, and 21 have any law pertaining to minors’ access, adoption of formal regulations may be an important first step to protect customer safety.15
Measurement of compliance with or enforcement of the laws was beyond the scope of this study. Studies have shown that, even when regulations exist, there is generally low compliance by facilities.15,29-31
Even the most stringent/comprehensive of laws, without enforcement, may have a limited impact, although education of tanning facility operators about regulations may help improve compliance with laws, and ultimately patron safety.32
We contend that the law stringency instrument offers a reasonable methodology for measuring states’ efforts to protect consumers from indoor tanning risks. The instrument’s stringency items and subscales could highlight what changes are needed, serving as a blueprint for a state’s indoor tanning control efforts. Likewise, the instrument could be used to demonstrate improvement in the quality of a state’s indoor tanning laws. Finally, the instrument could be used to assess the impact of the stringency of a state’s policy on residents’ behavior and health status.