To our knowledge, this study is the largest study to date assessing indoor tanning facility practices regarding youth access. Our data on the proportion of facilities requiring parental consent—approximately 87% of all facilities—were encouraging. Two previous studies also found relatively high rates of facilities requiring parental consent. 11, 22
In both of those studies, as in ours, the confederates' ages were explicitly provided at the beginning of the interaction. In contrast, studies using face-to-face methods have found more lenient parental consent practices. 9, 10
The different patterns in findings between these phone versus in-person data collection methods may be due to facilities' tendency to be stricter during the phone call (when a “sale” is more abstract).
Results from our multivariate analysis suggested that being in a state with any type of youth access law made it significantly more likely that a facility would require written consent. Also, the more tanning beds a facility had, the more likely the facility was to require consent. This latter finding may be due to the association between facility type and number of beds, with sole-purpose tanning salons having more beds than other types of facilities. It is these salons that are most likely to be part of a well-organized tanning industry network, in which facility owners are encouraged to comply, at least on the surface, with existing laws.10, 23
Although banning a 15-year-old prospective customer was infrequent among all facilities in our sample, the Wisconsin facilities had a moderately high rate of complying with this aspect of their law. Our rate of 70% for banning a 15-year-old in Wisconsin was comparable to the 77% rate in Wisconsin found by Hester et al.11
Moreover, Hester et al. reported that for a prospective 12-year-old client, 89% of Wisconsin facilities claimed they would implement a ban.11
Banning by facilities was substantially less common than requiring parental consent. Unlike a parental consent policy, which still provides the possibility of a sale as long as the parent agrees,24
imposing an absolute ban on adolescents, who may constitute a considerable proportion of a facility's profits, would be “bad for business”.
Compliance with FDA recommended session-per-first-week frequency was less than 11% in the present study, with 71% of facility staff allowing the confederate to tan every day, and these findings are similar to results from several previous studies. 8,12,13,22
These data highlight the deficiencies in having recommendations versus enforceable requirements. Not only do facilities allow frequent tanning, but they promote it using “unlimited tanning” discount price packages; these packages are ubiquitous in the U.S. tanning industry.13
Unfortunately, frequent use of indoor tanning is likely to increase melanoma risk of individual customers by promoting greater cumulative UVR exposure.25, 26
Our study had several methodological limitations. First, we were not able to send confederates in person to assess practices. However, when we attempted to validate our telephone method against in-person visits in a pilot study, concordance was acceptable.12
A second limitation is that our confederates were older than 15 years, and even though their voices were relatively high-pitched and youthful sounding, they may have produced different reactions from facility staff than actual teens. Third, we conducted only one contact, with only one respondent, per facility. Therefore, it is possible that our data may not represent the “typical” practices of all personnel at a given facility. Fourth, our results may not generalize to facilities in smaller cities or rural areas. Fifth, there may be potential confounders (that we neglected to measure) of the associations we found in the analyses. Finally, the cross-sectional design precludes making definitive conclusions about causal relationships between correlates and the facilities' practices. Methodological strengths of our study included a wide geographic area and large numbers of cities and facilities, assessment of several key practices that could influence exposure to artificial UVR by youth, inclusion of current legislative data as a potential correlate, and highly reliable data.
These data have important implications related to the safety of adolescent indoor tanners. The majority of facility personnel stated that a teen could tan every day the first week. This finding highlights the high level of UV exposure teens may be getting from indoor tanning. Non-regulated indoor tanning frequency schedules potentially could result in overexposure and burning. Therefore, regulation and enforcement of tanning schedules are warranted.
Are youth access laws, in general, and parental involvement laws, in particular, effective? Should more states pass these types of legislation? As noted above, having any youth access law was associated with significantly higher rates of requiring parental consent and parental accompaniment, and facilities in states with laws specific to these practices had considerably higher rates than facilities in states without comparable law content. Thus, at one level, if one defines success as facility compliance, our data could mean that the laws are having an impact. However, given the relatively high rates of indoor tanning by adolescent girls, as well as the potentially important gatekeeping function of parents, 24, 27
apparently many parents are allowing their teens to tan and are providing written consent or accompaniment.
Therefore, we encourage more states to adopt indoor tanning bans for minors. In fact, the World Health Organization (WHO) has recommended banning those under 18 years from commercial indoor tanning.28
To date, three Australian states and France have banned those under age 18.29-34
In the U.S., as of June, 2008, a pending law in Ohio would ban those under 18 years old.35
Bans such as these may both reduce youth access in a direct way and more forcefully educate parents about the real dangers of indoor tanning.