What information should the nurse include when reinforcing teaching about decreasing the risk of developing skin cancer?

ATI Med-Surg proctored Exam

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the

following instructions should the nurse include in the teaching?

1) Take temperature once a day.

2) Wash the armpits and genitals with a gentle cleanser daily.

3) Change the litter boxes while wearing gloves.

4) Wash dishes in warm water.

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and

tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this

client's secretions?

1) Provide humidified oxygen.

2) Perform chest physiotherapy prior to suctioning.

3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.

4) Hyperventilate the client with 100% oxygen before suctioning the airway..

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and

reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse

take to promote the client's comfort?

1) Rub the client's feet briskly for several minutes.

2) Obtain a pair of slipper socks for the client.

3) Increase the client's oral fluid intake.

4) Place a moist heating pad under the client's feet.

A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the

prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?

1) Emesis of 100 mL

2) Oral temperature of 37.5° C (99.5° F)

3) Thick, red-colored urine

4) Pain level of 4 on a 0 to 10 rating scale

A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a

hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of

the hypothermia blanket?

1) Shivering

2) Infection

3) Burns

4) Hypervolemia

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of

the following statements by the client indicates an understanding of the teaching?

1) "I will carry a complex carbohydrate snack with me when I exercise."

2) "I should exercise first thing in the morning before eating breakfast."

3) "I should avoid injecting insulin into my thigh if I am going to go running."

4) "I will not exercise if my urine is positive for ketones."

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is

postoperative. After calling for assistance, which of the following actions should the nurse take first?

1) Cover the client's wound with a moist, sterile dressing.

2) Have the client lie supine with knees flexed.

3) Check the client's vital signs.

4) Inform the client about the need to return to surgery.

Most skin cancers are at least partially caused by UV exposure, so reducing exposure reduces skin cancer risk. However, one out of every three U.S. adults has been sunburned in the past year, and most do not take recommended actions to protect themselves from the sun.227,228 In addition, indoor tanning rates are high among some groups, such as young, non-Hispanic white females, and skin cancer incidence rates are increasing. These facts show a need to take action to improve sun protection behaviors and address the harms of indoor tanning.

For Individuals

Sun protection helps prevent the harmful effects of sun exposure, including sunburn, skin cancer, premature skin aging, and eye damage. When used as part of a comprehensive approach, well-tailored, individual-focused strategies may be effective for reaching specific subpopulations.229,230 According to WHO's International Agency for Research on Cancer (IARC), ideal sun protection involves several behaviors, including

• Wearing tightly woven protective clothing that adequately covers the arms, torso, and legs.

• Wearing a hat that provides adequate shade to the whole of the head.

• Seeking shade whenever possible.

• Avoiding outdoor activities during periods of peak sunlight (such as midday).

• Using sunscreen (in conjunction with other sun protection behaviors).231

Federal agencies and other health organizations in the United States all provide recommendations for sun protection (see Table A in Appendix 5). These recommendations vary across agencies and organizations, often reflecting the specific area of focus for each institution (such as cancer or dermatologic conditions). Strategies for protection are often listed in varying order and do not always follow guidance from the IARC that sunscreen should be used in combination with other methods.231,232

Recommendations also do not often describe how to use sunscreen appropriately in terms of the amount to apply, the need to pre-apply some sunscreens before going out into the sun, and the need to reapply. These differences in sun protection messaging indicate missed opportunities for coordination across health organizations and highlight the need for more messaging about sun safety that is consistent and clear.232

Sun Protection Strategies

Wear Protective Clothing

When possible, wear long-sleeved shirts and long pants and skirts, which can provide protection from UV rays. Clothes made from tightly woven fabric offer the best protection. A wet T-shirt offers much less UV protection than a dry one, and darker colors may offer more protection than lighter colors. Some clothing certified under international standards comes with information on its UV protection factor.

Wear a Hat and Sunglasses

Wide-brimmed hats that shade the face, ears, and back of the neck provide the most protection. Tightly woven fabrics, such as canvas, provide the best protection; straw hats with holes that let sunlight through do not provide adequate protection. A darker hat may offer more UV protection. In addition to a hat, sunglasses that block as close to 100% of both UVA and UVB rays as possible can provide extra eye protection. Most sunglasses sold in the United States, regardless of cost, meet this standard. Wrap-around sunglasses work best because they also block UV rays from the side.

Seek Shade

An umbrella, tree, or other shelter can provide protection from the sun and relief during hot weather. Shade does not block all UV radiation if it does not block all of the sky, nor does it protect against scattered UV rays. For this reason, shade should be combined with other methods, such as protective clothing, especially in areas with highly reflective surfaces, such as snow, water, and sand.

Avoid Times of Peak Sunlight

UV radiation from the sun is most intense during the midday hours of 10 am to 4 pm (daylight savings) or 9 am to 3 pm (standard time), so scheduling outdoor activities earlier or later in the day can reduce UV exposure. UV radiation is also more intense during the late spring and early summer, at higher altitudes, closer to the equator, and when reflected off surfaces such as snow, water, and sand.233 Different surfaces have different reflectivity and can increase exposure. Snow reflects 80%–90% of UV radiation, sand 20%–30%, and water 5%–7%.233 Man-made surfaces can also have increased reflectivity. Concrete has been measured to reflect 14%–15% of UV rays, whereas grass only reflects about 1%–2% of UV rays.234 When near highly reflective surfaces, extra care should be taken to protect from UV exposure.

Use Sunscreen

Sunscreen should be used with other sun protection behaviors and applied to any exposed skin before going outside. For adequate protection, sunscreen should have an SPF of 15 or higher. SPF is a measure of how much UV radiation is required to produce a sunburn with sunscreen applied to the skin in relation to the amount required to produce a sunburn on unprotected skin. As the SPF increases, the amount of protection increases.235 Sunscreen should also have broad spectrum protection, which means that it protects against both UVA and UVB radiation.

Sunscreen is one of the most common methods of sun protection used by Americans.227 When used as directed with other sun protection measures, broad spectrum sunscreen with an SPF of 15 or higher helps prevent sunburn and reduces the risk of early skin aging and skin cancer (melanoma and SCCs) associated with UV radiation.99,231,236-238 Sunscreens with lower SPFs, or without broad spectrum protection, also help prevent sunburn but do not offer sufficient protection against early skin aging and skin cancer.

Sunscreen is most effective when used with other methods of sun protection. Current recommendations also state that sunscreen should be reapplied every 2 hours and after swimming, sweating, and toweling off.239 Some have suggested that a one-time reapplication 15–30 minutes after the original application may increase sunscreen's protectiveness against total UV exposure.240 When used incorrectly, sunscreen may provide a false sense of protection, which can ultimately lead to increased duration of sun exposure.231

Although concerns have been raised about real-world efficacy (because many people do not follow label instructions, use enough sunscreen, or reapply it often enough), broad spectrum sunscreens with an SPF of 15 or higher are effective at reducing the risk of skin cancer.241 Future scientific assessments are expected to provide more information about the long-term safety of frequent sunscreen use in people of all ages.

Avoid Indoor Tanning and Sunbathing

In addition to using sun protection when outdoors, avoiding intentionally tanning can help prevent skin cancer. Similar to excessive sun exposure, indoor tanning is associated with an increased risk of melanoma, SCC, and BCC.118-120 Indoor tanning also causes premature skin aging, such as wrinkles and age spots.143,242 Intentionally tanning the skin in the sun is an additional source of unnecessary and easily avoidable UV exposure.

Barriers to Using Sun Protection

Many Americans lack a general knowledge or awareness about the risks associated with sun exposure, or they think they are at low risk of developing skin cancer or sunburn.63,243,244 Some groups of Americans, especially blacks, the elderly, and people with less education, may perceive themselves to be at low risk of skin cancer.63 Because of the perception of low risk and a lack of awareness, these groups tend to be diagnosed with skin cancer at later stages.78,96,245

A substantial segment of U.S. adults also do not perceive cancer as preventable and thus may be less likely to engage in skin cancer prevention practices, such as using broad spectrum sunscreen with an SPF of 15 or higher or covering up.246 Lack of understanding of the UV Index is also a barrier to making informed decisions about adequate sun protection while outdoors.247,248

Many Americans either do not use sun protection when outdoors or do not use adequate protection, and as a result, they experience sunburn.227,228 The costs of protective clothing (e.g., wide-brimmed hats and sunglasses) and sunscreen may pose financial problems for some.243,249 Personal clothing style preferences can also create barriers to people using certain protective clothing items if they are seen as unfashionable, uncomfortable, or interfering with sports or other outdoor activities.243 For some people, protective clothing may interfere with the body's ability to cool itself, increasing the risk of heat illness.250,251

Reported barriers to sunscreen use include a perception that it is too messy, inconvenient, or feminine.243,252 Some sunscreen users may view sunscreen use as a way to stay out in the sun longer without getting burned.231,243 Others may use sunscreen for protection, but use it improperly by not applying enough or forgetting to reapply.243,253 Sunscreens may be somewhat less effective than physical barriers, and some people may have skin sensitivities or concerns about certain chemicals in sunscreens.241,254

High melanoma incidence and death rates among older non-Hispanic white men demonstrate the need to increase sun protection among males, especially adults.9 Higher rates observed among older men may be due to less use of sun protection and more time spent outdoors throughout life compared with women.117,227,231 Men are less likely to use personal care products that contain sunscreen, and they may be less influenced by social pressures to avoid premature skin aging.231 For this reason, clothing and wide-brimmed hats may be particularly important strategies for males. Baseball caps do not provide adequate sun protection on their own, because they leave the ears and the back of the neck exposed.228,255

If not addressed in a coordinated way, physical activity and sun protection messages can conflict. Staying out of the sun at peak hours may not be feasible, depending on recreational and occupational activities and schedules. Reapplication of sunscreen can be difficult during activities such as sports events or practice.250,256 Engaging in physical activity outdoors is associated with overexposure to UV radiation and sunburn.257 However, findings from one study suggest that the promotion of sun safety is not likely to reduce physical activity among children.258

Barriers to Reducing Intentional Tanning

Intentional tanning, which includes both indoor tanning and seeking a tan outdoors, is strongly associated with a preference for tanned skin and other appearance-focused behaviors.259-262 Studies indicate that messages that focus on the effects of indoor tanning that are related to appearance, such as premature skin aging, may be more effective for tanners than health-focused messages and may even promote long-term behavior change.263-266

Patterns of indoor tanning vary, with some people tanning only before special events, such as proms, and others tanning sporadically or regularly. Strategies that tailor prevention messages to specific types of tanners are likely to enhance the effectiveness of interventions.230,267 Additional strategies may be needed to prevent the initiation of intentional tanning. Indoor tanners may incorrectly believe that tanning indoors has health benefits or that it is safer than tanning outdoors because it is regulated.211,268,269

Researchers are currently examining the psychological effects of indoor tanning and possible links between indoor tanning behavior and dependence and addiction.270 Indoor tanning appears to have reinforcing properties similar to those ascribed to addictive substances, such as the release of endorphins when the skin is exposed to UV radiation.270-272 Endorphins are a type of natural opioid involved in the brain's reward pathway. Their production during indoor tanning could create a future incentive to tan.271

Social Norms Regarding Tanned Skin

Social norms regarding tanned skin as attractive and healthy create barriers to reducing intentional exposure to UV radiation, whether indoors or outdoors. In many communities and social groups, tanned skin is considered attractive,273 and social pressures to conform to this beauty standard can be powerful motivators.274 Women in particular may experience greater social pressure to tan and have tanned skin, which likely explains the higher rates of indoor tanning observed among women than men.133,134,259,273-275

Social norms regarding tanned skin have changed over time. Before the 1920s, pale skin was considered beautiful and an indication of upper class lifestyles, while tanned skin was a sign of working class people who labored outdoors.276 As the industrial revolution moved the working class indoors and into crowded inner cities, pale skin was no longer viewed as a sign of wealth, but rather an indicator of poverty and poor health.276 Tanned skin began to signify a life of leisure and disposable income that allowed time for outdoor sports and beach vacations.211,276

Although messages about the risks associated with excessive sun exposure and indoor tanning have become more common in recent years, many still consider tanned skin to be a sign of health, fitness, youth, and attractiveness,211,276 and this viewpoint is often perpetuated in popular media.260 To be successful, future efforts to improve sun protection behaviors, reduce indoor tanning, and prevent skin cancer will likely need to address the underlying motives that drive behaviors associated with skin cancer risk, such as the desire to look attractive and healthy and to conform to societal beauty standards. For example, future messages could focus on the appearance-related harms of excessive UV exposure and how most people do not use indoor tanning devices.265,277-279

To reduce harms from indoor tanning, some organizations have promoted the use of topical sunless tanning products as a way to get a tanned appearance without UV exposure.260 One concern about this method of tanning is that dihydroxyacetone (DHA), a commonly used ingredient in sunless tanning products, is approved by FDA for use in cosmetics and drugs for external application only (21 CFR Part 73).280 When this product is used in spray tanning booths (spray-on tans), inhalation is usually unavoidable.260 In addition, the promotion of sunless tanning products does not address the underlying social norms that drive tanning behaviors. Sunless tanning products are often used in conjunction with, rather than in place of, UV tanning.281-285 Furthermore, their use does not appear to lead to safer outdoor sun exposure and could potentially increase the likelihood of sunburn.282,286,287 Other methods used to achieve tanned skin, such as pills and injections, have additional health risks.288 However, over-the-counter sunless tanning creams and lotions may be an option for those who want to have tanned skin while avoiding the health risks of UV exposure and inhaled and absorbed DHA.

For Clinicians

Evidence demonstrates that clinicians can play a role in reducing UV exposure through individually directed counseling, particularly among adolescent and young adult patients with fair skin.265,289 Federal agencies and the independent U.S. Preventive Services Task Force (USPSTF) recently conducted a systematic review of the evidence on the effectiveness of behavioral counseling to prevent skin cancer. Findings from the review indicated that counseling in primary care settings can increase sun-protective behaviors and decrease intentional tanning, including indoor tanning.277,278 On the basis of these findings, the USPSTF now recommends that clinicians counsel patients with fair skin aged 10–24 years to minimize their UV exposure to reduce their risk of skin cancer.265,277,278

Effective interventions are generally of low intensity, are completed almost entirely during the primary care interaction or visit, and use cancer prevention or appearance-focused messages to reach specific audiences.265,277,278 Appearance-focused messages are successful at reducing intent to pursue indoor tanning among late-adolescent women (the population most likely to engage in indoor tanning).265,277,278 Efforts are needed to identify ways to disseminate this type of information to clinicians and provide them with effective, user-friendly tools to use with patients. Evidence of the benefits of counseling for patients older than age 24 is sparse and insufficient to serve as a basis for a recommendation.

Some groups recommend periodic skin cancer screening1 either by a health care provider or by self-examination.290,291 Consistent and regular screening identifies melanomas that are, on average, thinner than those found during usual care. Whether detection of these lesions leads to fewer cases of disease or death is unknown.292 For this reason, the USPSTF has stated that current evidence is insufficient2 to recommend skin cancer screening by primary care providers among the general U.S. adult population. On May 15, 2014, the USPSTF released a draft research plan, which will be used to guide a systematic review of the evidence by researchers.293 Although screening is not currently recommended, providers should remain alert to suspicious lesions. For more information on skin cancer screening, see Appendix 3.

For Communities and Schools

Community-level intervention strategies vary greatly by audience, setting, duration, and the number and types of included components. For some strategies, sufficient evidence is available to recommend dissemination. For other strategies, more research is needed to determine basic effectiveness before the intervention can be disseminated to other communities. For specific examples of community-level interventions, see Appendix 4.

Current Evidence on Effective Community-Level Interventions

Federal agencies and the independent Community Preventive Services Task Force have worked together to conduct systematic reviews of the evidence on the effectiveness of community-based interventions to prevent skin cancer. Findings from an initial review were published in 2003 and 2004 and used as the basis for recommendations for interventions designed to prevent skin cancer made by The Guide to Community Preventive Services (The Community Guide3).28,294,295

The Community Guide states that sufficient evidence exists to recommend multicomponent, communitywide interventions,4 as well as interventions designed for certain settings (specifically, child care centers, primary and middle schools, outdoor recreational and tourism settings, and outdoor occupational settings).296 The Community Guide states that insufficient evidence exists to recommend mass media campaigns alone or to recommend skin cancer prevention interventions in other settings (high schools, colleges, and health care settings5).296 Although some skin cancer prevention interventions have been shown to be effective in these settings, more research is needed before these findings can be translated into evidence-based recommendations for skin cancer prevention interventions.296 Efforts to update these recommendations to reflect the latest evidence are ongoing. The current recommendations for skin cancer prevention, which are based on updated reviews, are available online at http://www.thecommunityguide.org/cancer and are summarized in Table B in Appendix 5. The recommendations provided in this Call to Action are consistent with The Community Guide.

SKIN CANCER PREVENTION IN ACTION: RECREATIONAL SETTINGS

Pool Cool: Sun Safety for Outdoor Swimming Pools

Pool Cool is a sun-safety education program for children aged 5–10 years and their parents, as well as for pool staff and other pool users. It is being used at public pools across the United States. The program is centered on eight brief sun-safety lessons that are taught at the beginning of regular swim classes. The program also promotes the creation of sun-safe pool environments that include shaded areas, signs to promote sun safety, and sunscreen dispensers.

First piloted in Hawaii and Massachusetts, Pool Cool has been used and evaluated at more than 400 pools across the country. These evaluations found that pools that use the program have more protected pool environments, better sun protection habits among children and parents, and fewer sunburns among children and lifeguards. For more information about the Pool Cool program, visit http://www.med.upenn.edu/poolcool/.

Prevention Policies in Schools

Sun protection programs for children can have important benefits.297 Sunburns in childhood are a clear risk factor for skin cancers later in life, and building healthy habits early when children are more receptive can lead to increased sun protection into adulthood.297,298 Given the amount of time children spend in school settings, much of the skin cancer prevention efforts for children have focused on sun-safety education in schools and changes to the school environment to promote sun-safe behaviors. This section provides examples of the resources available to schools and an overview of policies used in some schools to promote sun safety.

Sun protection policies can be implemented at the school, community, school district, or state level. CDC's School Health Policies and Practices Study (SHPPS) collects data from a nationally representative sample of public school districts to assess school health policies and practices in the United States. According to 2012 SHPPS data,299 some U.S. school districts have policies to promote sun safety among their students. Although very few districts had policies that required specific sun-safety strategies, many districts had policies that recommended the following:

• Allowing students to apply sunscreen while at school (44.4%).

• Encouraging students to wear hats or visors (36.1%), protective clothing such as long-sleeved shirts or long pants (39.6%), and sunglasses (25.0%) when in the sun during the school day.

• Scheduling outdoor activities to avoid times when the sun is at peak intensity during the school day (38.3%).299

A baseline assessment of school policies collected during 2005–2007 from 112 public school districts in Colorado and California found that 52% of school districts in California and 8% in Colorado had at least one policy on sun protection before a randomized intervention was implemented.300 After the randomized intervention, districts appeared to adopt stronger policies than districts that did not participate in the intervention.301 Some states require public schools to provide information on sun safety and skin cancer prevention.302,303 For example, since 2004, Arizona has mandated that all public schools teach EPA's SunWise program (http://www.epa.gov/sunwise; SunWise box, page 32) from kindergarten through eighth grade.303,304 Across the United States, teachers taught sun safety or skin cancer prevention in at least one class as part of required health instruction in 68% of elementary schools, 76% of middle schools, and 78% of high schools in 2006.305

Box

SUNWISE: SUN SAFETY FOR KIDS AND EDUCATORS. SunWise is the most widely used health and environmental education program for sun safety in the United States. It is designed to teach children aged 5–15 years and their caregivers how to protect themselves (more...)

Barriers to Interventions in Schools and Communities

Effective strategies can improve sun protection behavior in children and adults, particularly in child care, school, and outdoor recreational and tourism settings (Table B, Appendix 5).306 But without widespread, comprehensive implementation, these strategies may have little effect on sun protection behaviors and sunburn prevention at the community level. Single-component interventions may only have a small effect on behavior change, which may not be sufficient to reduce skin cancer risk.307 In addition, school policies can either support or pose barriers to sun protection. Currently, some schools and school districts do not allow certain kinds of protection to be easily used, because of rules such as bans on hats and sunglasses or provision of sunscreen only by prescription or by a school nurse.300 Policies allowing the use of sun protection in schools can help support broader efforts.

Social and contextual factors within communities can also create barriers to reducing UV exposure. For example, outdoor environments, such as community parks and school playgrounds, often lack adequate shaded areas. Providing shade, either in the form of man-made shade structures or natural shade from trees and shrubs, can help people enjoy the outdoors at any time of day without the risk of excessive sun exposure.308

For Outdoor Work Settings

Similar to schools, outdoor work settings are an important setting for efforts to prevent overexposure to the sun and reduce skin cancer risk. Research has shown that skin cancer prevention interventions designed to reach outdoor workers can be highly effective at increasing sun protection behaviors and decreasing sunburns.309

According to The Community Guide,309 effective interventions include one or more of the following:

• Educational approaches, such as messages about sun protection delivered to workers through instruction, small media (e.g., posters, brochures), or both.

• Activities designed to influence the knowledge, attitudes, or behavior of workers, such as modeling or demonstrating behaviors.

• Environmental approaches to encourage sun protection.

• Workplace policies that support sun protection practices.

A study in Australia found that workers who were more aware of sun safety or who worked in smaller workplaces were more likely to use protection when they received instructions on its use.310 Other studies have found that being employed in a workplace that is perceived to be supportive of sun protection is associated with better sun protection behaviors among workers.311 In addition to employers, local governments and labor organizations have played a role in increasing programs for sun protection among outdoor workers.312,313

State and Local Policies, Legislation, and Regulation

Intervention strategies that address social and contextual factors have the potential for broad public health impact by making the healthy choice the easy or default choice.314 Policies, legislation, and regulation are examples of such interventions, reaching wide segments of communities while requiring minimal individual effort compared with interventions directed at individuals.314

Sun Protection Policies and Legislation

Sun Protection

Many schools have policies that limit students' ability to use sun protection, such as dress codes that prohibit the use of hats or sunglasses or policies about over-the-counter drugs that prohibit the use of sunscreen.300 Only a few states, such as California and New York, have passed legislation requiring that schools allow students to use sun-protective clothing (California) or sunscreen (California and New York) on campus.315,316 The California School Boards Association recommends that individual school districts adopt specific sun protection policies for students.317,318 In addition, lifeguards in California who get skin cancer are eligible for workers' compensation benefits under certain conditions.319 California law also urges employers to identify and correct workplace hazards connected to UV radiation.320

Local policies that address skin cancer prevention vary across the country, and their effects on the incidence of skin cancer or on intermediate outcomes, such as sun protection behaviors and sunburn, have not been formally evaluated or documented. However, such policies could be considered as one component of a larger, more comprehensive skin cancer prevention initiative within a community.

Education and Awareness

A few states have passed legislation to support sun-safety education programs and skin cancer prevention awareness. Laws in Arizona and New York mandate instruction on skin cancer prevention as part of the health education curriculum in public schools.303,321 In 2004, Arizona adopted a law requiring implementation of the state's SunWise school program (adapted from EPA's SunWise program; see box, page 32) in grades K–8 in all public schools.303,304 In 2006, Kentucky passed a law encouraging skin cancer education in schools.322

Photo courtesy of Queensland Department of Health

Some states have policies that reach beyond children as the audience for education and awareness. New York mandates sun-safety education for all state employees who spend more than 5 hours a week outdoors.323 In 2009, Arkansas began providing grants to organizations that provide skin cancer education to state citizens.324 Florida has included skin cancer prevention in its health awareness campaign program since 2004, reaching a wide range of the state's population.325

Indoor Tanning Policies and Legislation

Some states and municipalities in the United States have regulations relating to the use of indoor tanning devices. As with many public health issues, regulation of indoor tanning is likely to be most effective if combined with a multifaceted approach. For example, monitoring use of indoor tanning devices and changes in use over time, restricting use of tanning devices to protect certain populations (e.g., minors, people with fair skin, people at increased risk because of a family or personal history of skin cancer), offering safe alternatives to indoor tanning, warning users about the health risks associated with indoor tanning, and enforcing existing regulations could help reduce harms.328

Considerable variation exists throughout the country in the strength and enforcement of indoor tanning restrictions, as well as compliance with these restrictions. In October 2011, California passed the most stringent youth access law in the country, which took effect on January 1, 2012, and prohibits indoor tanning for anybody younger than age 18 years (Figure 9).329 Since then, Vermont, Nevada, Oregon,6 Texas, Illinois, Washington,6 Minnesota, Louisiana, and Hawaii have also adopted prohibitions on indoor tanning for minors younger than age 18 years.329-331 Several additional states proposed legislation to enact bans on indoor tanning for this age group during the 2013–2014 legislative session.329,330

Figure 9

Legislative Restrictions on Access to Indoor Tanning by Minors in the United Statesa. a Map represents legislation passed before July 10, 2014. Note: State laws in Oregon and Washington allow minors younger than age 18 years to use indoor tanning facilities (more...)

Currently, at least 44 states and the District of Columbia have some kind of law or regulation related to indoor tanning,329-334 including the following:

• Bans on indoor tanning for minors under a certain age, ranging from 14 to 18 years.

• Laws for minors requiring parental accompaniment or parental permission.

• Harm-reduction regulations (for all ages) that require use of eye protection or limit exposure time.

Indoor tanning laws, particularly those that include age restrictions, appear to be effective in reducing indoor tanning among female high school students, who have the highest rates.335

Many states require that tanning salons be licensed or registered and that they provide information on the risks of tanning to customers; some require that tanners sign a warning statement before tanning.336 Other legislative approaches include time limits, UV irradiance or exposure limits, requirements that warning statements be signed or posted, mandatory eyewear, mandatory reporting of incidents, penalties for violations of existing regulations, and training requirements.336 The strength of state laws varies, and some states have no laws relating to indoor tanning.336 Restrictions on indoor tanning also exist at local levels. For example, indoor tanning is prohibited among minors younger than age 18 in Chicago and Springfield, Illinois, and in Howard County, Maryland.329

Evidence suggests that bans on underage tanning are effective in reducing access to and use of indoor tanning among minors.335,337 According to a 2003 telephone survey of randomly selected indoor tanning salons in three states—Texas, Illinois, and Wisconsin—that banned indoor tanning by youth younger than age 13, 14, or 16 years, respectively, 62% of facilities contacted stated that they would not allow a 12-year-old to tan, whereas only 18% of facilities in a state without age restrictions (Colorado) would prohibit such use.337 A study of the recently enacted under-18 ban in California found that 77% of salons would not allow a 17-year-old to tan.338 Another recent study found that indoor tanning laws, particularly those with age restrictions, are associated with lower rates of indoor tanning among female adolescents.335

Laws that require parental consent for tanning by youth under a particular age have the potential to be effective at reducing youth indoor tanning, but more evaluation is needed. In 2009, researchers published results of a study of more than 3,600 indoor tanning facilities nationwide.339 Data collectors called the facilities, posing as prospective fair-skinned, 15-year-old customers who had never tanned before. Of the 20 states with parental consent laws at the time of the study, facilities sampled in only four states (Louisiana, Maine, New Hampshire, and South Carolina) uniformly stated that they would require 15-year-old customers to obtain parental consent to tan.339 Facilities in Georgia had the lowest level of compliance (72.5%).339

Other smaller studies confirmed low compliance. In a 2005 study, 15-year-old girls visited 200 indoor tanning facilities in Minnesota and Massachusetts, posing as potential customers. In 2005, both states had laws requiring parental permission for indoor tanning by youth (younger than age 16 years in Minnesota or 18 years in Massachusetts). However, 81% of the facilities sold the girls tanning sessions without parental consent.340 A 2001 study of 54 salons conducted in San Diego, California, found that 43% of facilities visited would have enforced the existing parental accompaniment consent law.341 These data indicate the need for, and importance of, enforcement of regulations or laws that may be effective at reducing youth indoor tanning.

Training requirements for tanning facility employees also vary by state. Some require that a salon must have at least one trained operator on site while tanning beds are in operation.342 Others require training for all tanning salon employees.334,343-345 Likewise, the extent and rigor of training required varies by state. For example, in Iowa, tanning bed operators are required to read a document on the risks of tanning provided by the state health department and complete an assessment.346 Florida requires that all tanning salon employees and tanning bed operators complete a training course provided by a preapproved outside vendor. Many of the vendors are industry groups.345

Federal Policies, Legislation, and Regulation

Many federal departments and agencies work on efforts related to skin cancer prevention and control, individually and together. Federal agencies also disseminate information about what works to prevent skin cancer. The U.S. Department of Health and Human Services (HHS) and its agencies play important roles in skin cancer prevention at the federal level. These agencies include the National Cancer Institute (NCI) in the National Institutes of Health (NIH), CDC, FDA, and the Agency for Healthcare Research and Quality. CDC supports Comprehensive Cancer Control Programs in states, tribes, and territories, many of which conduct activities related to skin cancer prevention. Federal entities outside HHS also address skin cancer prevention, including the Federal Trade Commission (FTC), EPA, the National Park Service, and the Occupational Safety and Health Administration (OSHA).

Federal legislation can help support skin cancer prevention and control efforts. For example, the Affordable Care Act includes a 10% excise tax on indoor tanning services and a requirement that nearly all health insurance plans cover USPSTF-recommended preventive services. Recommended services include behavioral counseling for children, adolescents, and young adults aged 10–24 years with fair skin on how to minimize their exposure to UV radiation to reduce the risk of skin cancer.

For more information on federal activities related to skin cancer prevention, see Appendix 5.

Sun Protection Policies and Legislation

Sunscreens sold in the United States are governed by FDA as over-the-counter drugs. Regulations identify acceptable active ingredients and dosage strengths, provide language and format for product labels, and establish standardized test methods for determining a product's SPF, among other requirements. Products that satisfy regulatory conditions are considered to be safe, effective, and truthfully labeled and may be marketed without premarket review and approval by FDA. Products that vary from regulatory conditions may be sold only after FDA review and approval.187

Under FDA regulations, all sunscreen products are labeled for use to help prevent sunburn, and they must state the product's SPF. Sunscreens that pass a separate test for broad spectrum (UVA and UVB) protection may also be labeled as “broad spectrum.” In addition, broad spectrum sunscreens with SPF levels of 15 or higher may be labeled as reducing the risk of skin cancer and premature skin aging when used together with other sun protection measures, including limiting time in the sun and wearing long-sleeved shirts, pants, hats, and sunglasses.

Broad spectrum sunscreens with SPF levels above 2 but below 15 must be labeled with a “Skin Cancer/Skin Aging” alert in the warning section of the label. This alert states the following: “Spending time in the sun increases your risk of skin cancer and early aging. This product has been shown only to help prevent sunburn, not skin cancer or early skin aging.”187,347

FDA regulations do not allow for the terms “waterproof” or “sweat proof” because no product has been shown to completely retain its effectiveness regardless of the time a person is immersed in water. Only the term “water resistant,” followed by the length of time of demonstrated water resistance (40 or 80 minutes), is allowed to appear on sunscreen labeling.187,347

Indoor Tanning Regulations

At the federal level, FDA regulates indoor UV tanning devices under separate authorities, both as medical devices and as radiation-emitting electronic products. Manufacturers of indoor tanning devices (also known as sunlamp products) are required to certify that their products comply with the FDA Performance Standard for Sunlamp Products (21 CFR 1040.20).348 FDA originally classified indoor tanning devices as Class I (low risk) medical devices, suggesting that they posed minimal dangers to consumers. FDA is working to reflect current science on the risks of indoor tanning, improve the visibility and readability of the warning label, update and promote compliance with the performance standard, and help reduce harms from these devices through regulatory mechanisms. On May 29, 2014, FDA reclassified indoor tanning devices as Class II medical devices (moderate to high risk) (see Appendix 5 for more information).349-352

Once the reclassification order is effective,350 manufacturers will have to do the following:

• Include a visible black box warning on the tanning device that people younger than age 18 years should not use these devices.

• Receive premarket notification 510(k) clearance from FDA for newly marketed devices (which were previously exempt from any premarket review).

• Show that their products have met certain performance testing requirements.

• Address certain product design characteristics.

• Provide comprehensive labeling that presents consumers with clear information on the risks of use.

Although the effect of strengthening FDA regulation is currently unknown, estimates from Australia suggest that strengthening and enforcing regulations restricting indoor tanning among minors and people with Fitzpatrick Skin Type 1 could result in 18–31 fewer diagnoses of melanomas per 100,000 and 200–251 fewer diagnoses of SCC per 100,000 each year in that country.353

Barriers to Addressing Indoor Tanning Through Policies, Legislation, and Regulation

Ubiquity of Indoor Tanning Devices

The ubiquity of indoor tanning salons and the low cost of indoor tanning may be important barriers to reducing harms from indoor tanning. A study found an average of 42 indoor tanning salons in major U.S. cities in 2006.354 The study also found that cities with higher percentages of whites had significantly higher facility densities than those with lower percentages of whites and that living within 2 miles of an indoor tanning facility was a significant predictor of indoor tanning among adolescents.354,355 In addition, indoor tanning devices are available for use in unsupervised settings, such as fitness centers and apartment complexes, which can promote frequent use and raises questions about the ability to enforce current and future regulations.356

Enforcement

Lack of enforcement creates a potential barrier to successful implementation of controls and can limit the effect these efforts could have on reducing indoor tanning. Studies examining state enforcement of indoor tanning laws and regulations raise concerns about the sufficiency of enforcement efforts. For example, a 2008 study in 28 cities found that routine annual inspections of indoor tanning facilities were conducted in only 36% of cities. Thirty-two percent conducted inspections less than annually, and about 32% did not inspect indoor tanning facilities for compliance with state laws. Officials in only 50% of cities stated that they would give citations to tanning facilities that violated laws.357

Compliance

FDA recommends limits on maximum exposure times, and FDA regulations require that the recommended exposure schedule appear on the label and in the instructions for sunlamp products.358 However, compliance with existing regulations and recommendations varies.136,341,359,360 A study of tanning salons in North Carolina found that 95% of patrons exceeded FDA exposure recommendations, and 33% of patrons began tanning at maximum doses recommended for maintenance tanning.136 Indoor tanning salons often use promotional pricing packages that promote frequent indoor tanning.260,359 A study of 54 tanning salons in San Diego found that 75% of advertisements and 100% of facilities offered “unlimited” tanning packages,341 which may encourage users to indoor tan in ways that are inconsistent with the intent of FDA exposure recommendations.

State regulation of indoor tanning devices, including restrictions on youth access, also varies considerably across the country, and studies examining state indoor tanning laws and regulations in the United States demonstrate that compliance with these laws is low and not adequately enforced.262,360 The study of tanning salons in San Diego found low compliance with some state and federal regulations, including posting of warning signs.341

Marketing

Marketing tactics used by the indoor tanning industry can also be a concern. In 2010, FTC sued the Indoor Tanning Association (ITA), a trade association representing the tanning industry, alleging false and misleading advertising about the health risks of indoor tanning (see Appendix 5).361 The settlement reached in this case prohibits the ITA from making the misrepresentations challenged in the complaint, misrepresenting any tests or studies, or providing deceptive advertisements to members. These prohibitions are applicable only to the ITA and related individuals and entities.

Evidence suggests that tanning industry members, including salon chains and individual salons, continue to make statements about indoor tanning that may be inconsistent with the available scientific evidence.260,360 For example, according to a 2013 report of the results of a telephone survey of 338 indoor tanning salons in California, 61% denied harms of UV exposure, and many made claims of health benefits from indoor tanning exposure.338 A 2012 report of the U.S. House of Representatives Committee on Energy and Commerce, Minority Committee, described the response of randomly selected tanning salons to calls from individuals posing as teenaged girls. According to the report, many of the salons stated that indoor tanning does not increase cancer risk, despite substantial evidence to the contrary.362

Lack of a Comprehensive Approach

Lack of a comprehensive, coordinated approach may also be a barrier to successful policy and legislative efforts. Without enforcement, certain restrictions may be easily circumvented. Stronger laws to regulate tanning salons and restrict youth access to them will not be as effective in the absence of increased controls on unsupervised tanning beds and direct sales to the public. Instead, they may drive people to indoor tan in unsupervised locations, such as gyms, beauty salons, or common areas of apartment complexes, or to buy tanning beds for home use. Unsupervised use of a tanning bed or use without a trained operator may lead to longer, more intense exposure to UV radiation. A qualitative study found that ownership of a tanning bed could lead to very high exposures. One participant shared that he would often fall asleep in his tanning bed, tanning for as long as 40 minutes at a time.7,211

A survey of British youth in 2010, before the United Kingdom enacted restrictions banning indoor tanning for all minors, found that 23% of youth aged 11–17 years had used an indoor tanning device at home, and 21% had used unsupervised devices in other settings.363 To prevent minors from accessing unsupervised tanning facilities where access is not controlled, WHO has recommended banning unsupervised tanning facilities as a complement to restricting the use of tanning beds by minors.356

International Efforts to Prevent Skin Cancer

Other countries have taken a variety of approaches to prevent skin cancer, including community-based, multicomponent interventions, which are recommended by The Community Guide.295 If these types of interventions include some level of continued support, they have demonstrated an ability to influence sun-protective behaviors.364 A study of an Australian skin cancer prevention program called SunSmart estimated that a national, ongoing program funded at historic levels ($0.12–$0.41 Australian dollars per year per capita) would save $2.30 in Australian dollars for every $1 invested. The program was also estimated to save 22,000 life-years in the state of Victoria, Australia, during 1988–2003.365 Data from the evaluation of the SunSmart program provide evidence that sustained funding for a community-level skin cancer prevention initiative can improve health outcomes and result in long-term savings in health care costs.

Some countries have also used mass media campaigns with varied success, but most of these efforts have not been formally evaluated. One particularly successful sun-safety campaign called Reduce Your Sun was implemented in Denmark.366 Since the campaign started in 2007, surveys have shown decreases in the percentage of Danes who sunbathe and who indoor tan.367 The Danish campaign made extensive use of social marketing and social media, including provocative videos designed to appeal to adolescents and young adults.366,368

Many countries have laws specifically addressing indoor tanning. In November 2009, based on WHO's designation of indoor tanning devices as Class 1 human carcinogens (the highest risk level), Brazil became the first country to ban indoor tanning for cosmetic purposes.369 In February 2012, New South Wales, Australia—home to more than 5 million people—passed a complete ban on indoor tanning, which will become effective on December 31, 2014.328 In addition, as of January 2014, France, Spain, Portugal, Germany, Austria, Belgium, the United Kingdom, Australia, Iceland, Italy, Finland, and Norway prohibit indoor tanning for youth younger than age 18 years; most of these laws have been in place since 2003.328,369

According to WHO,356 other approaches can include the following:

• Banning unsupervised indoor tanning devices (e.g., devices located in gyms or apartment common areas, coin-operated devices).

• Requiring eye protection.

• Restricting the use of indoor tanning by people at higher risk of skin cancer (e.g., those with Fitzpatrick Skin Type 1).

• Limiting the UV intensity emitted from devices.

• Requiring informational and warning notices.

• Conducting health education.

• Requiring informed consent to ensure that all users are aware of risks.

• Requiring training of tanning salon staff.

SKIN CANCER PREVENTION IN ACTION: MULTICOMPONENT EXAMPLE FROM AN INTERNATIONAL SETTING

SunSmart Australia: Lessons from International Success

Australia has the highest incidence of skin cancer of any country, and the disease costs the country's health care system more than $294 million in Australian dollars annually. In 1988, the state of Victoria launched the SunSmart program to encourage sun-protective behaviors and minimize the human cost of skin cancer.

This multicomponent, communitywide intervention is designed to raise awareness, change personal behaviors, and influence institutional policy and practices. Activities include mass media campaigns, programs in schools and work sites, a sports program, health care provider education, resource development and dissemination, and capacity building at the community level.

Since SunSmart began, rates of BCC and SCC skin cancers among people younger than age 45 years have begun to taper off, and increases in melanoma rates have stabilized.365,370 SunSmart is estimated to save $2.30 in health care costs for every $1 spent.365 For more information about the SunSmart Program, visit http://www.sunsmart.com.au.

Photo courtesy of Queensland Department of Health

1

Skin cancer screening is defined as an evaluation of the skin by a medical provider, in the absence of changes to the skin.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of this service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

The Community Guide is a website that houses the official collection of all Community Preventive Services Task Force findings and the systematic reviews on which they are based.

Multicomponent, communitywide interventions are defined as interventions that include at least two distinct components that are implemented in at least two different types of settings (e.g., schools, recreation areas) or that reach the entire community (e.g., mass media campaigns).

Community-based interventions in health care settings were last reviewed and recommendations were updated in 2002. These interventions are different from the provider counseling for fair-skinned youth aged 10–24 years, which the USPSTF has found to be effective.

State laws in Oregon and Washington allow minors younger than age 18 years to use indoor tanning facilities with a doctor's prescription.

Although indoor tanning devices sold in the United States are required to have timers that would automatically shut off the device after a certain period of time, these timers may be inoperative or possibly overridden by users. Data from the National Electronic Injury Surveillance System on visits to emergency rooms related to indoor tanning contain anecdotal reports of users falling asleep and being burned.

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