Amid the election-year fracas and continuing controversies about innumerable issues — from global warming to fuel costs, to political scandals and the ongoing Iraq war — another conflict is heating up, so to speak. It’s about tanning and sun exposure, and it’s between the tanning industry and the dermatologist community, the American Academy of Dermatology (AAD) in particular.
A Mixed Message
At issue is a new development in the longstanding debate over health risks associated with indoor tanning. That contentious issue took on a new, more visible dimension in March, when the Indoor Tanning Association (ITA) launched an aggressive multi-message advertising campaign disputing a link between tanning and melanoma, taking dermatologists to task for their connections with sunscreen manufacturers, and urging consumers to “rethink sun bathing” to increase vitamin D intake.
The cornerstone of the Washington, D.C., trade association’s campaign was a full-page print ad headlined “Tanning Causes Melanoma HYPE” (at right) that ran in the New York Times and other major newspapers, and a similarly themed message in a series of television commercials.
“This is an unprecedented campaign in its degree of aggressiveness. And it’s a bit of a smokescreen — nobody goes to a tanning parlor to make vitamin D,” says Tampa, FL, dermatologist and skin cancer specialist James Spencer, M.D., Associate Professor of Clinical Dermatology at the Mount Sinai School of Medicine in New York. “It’s one thing to say that vitamin D is good for you, quite another to say that the dermatologists are dirtballs. That’s scurrilous.” Previous industry campaigns, Dr. Spencer notes, have focused largely on the “cosmetic benefits” of tanning.
Responses
The AAD is currently developing a response to the ITA campaign and the industry’s messages on two newly created Web sites, www.SunlightScam.com and www.trusttanning.com. (In the interim, dermatologists are urged to refer to existing AAD materials and media tool kits, at www.aad.org/members/index.html.)
Why is the campaign so aggressive, and why is it being staged now? Several dermatologists with whom Skin & Aging spoke in mid-April pinned the timing to factors ranging from the increasingly stringent state regulatory environment regarding tanning-bed access by minors, to Congress’ recent passage of the so-called TAN Act (Tanning Accountability and Notification Act).
Among the states pressing for tighter regulation of children’s access to indoor tanning equipment, the Ohio legislature is currently considering a bill that would ban access to minors under age 18. The TAN Act, passed into law last fall, charges the U.S. Food and Drug Administration (FDA) with assessing the current warning label on tanning equipment, to ensure that its positioning and language adequately communicate potential health risks associated with excessive exposure.
“We think the current labeling is inadequate,” says Oregon dermatologist Diane Baker, M.D., Immediate Past President of the AAD Association, because it does not “specifically address skin cancer” risk.
Dr. Baker adds that she suspects the pending FDA actions have contributed somewhat to the tanning association’s campaign timing. But she thinks that the changing state regulatory environment and the industry association’s longstanding dispute with the AAD regarding its position statements on tanning avoidance are larger factors. “We’ve known for a long time that the industry takes exception to the point of view of dermatologists that tanning — specifically indoor tanning — is hazardous to your health and can induce skin cancers over the long term,” she says. “But I think it’s also the fact that dermatologists in several states have become more aggressive,” she adds, about pushing for stricter tanning-equipment use regulation and more specific health-risk warning wording.
“Over the years, various states have been chipping away at their [tanning salons] business, with more restrictive legislation regarding children — and you have to remember,” Dr. Spencer observes, “that high school cheerleaders and young women are a a big part of their business. They’re cash customers.” At present, 25 states have enacted age restrictions, including a handful that have added absolute age restrictions, ranging from 13 to 16 on tanning. Increasingly, states are moving toward requiring parental consent (in writing or by their on-site presence) for teens to use tanning facilities.
The ITA’s New Approach
On her first point about the tanning industry’s taking issue with dermatologists’ UV-exposure messages, Dr. Baker is correct, according to Indoor Tanning Association officials. ITA’s Commun-ications Director Sarah Longwell told Skin & Aging that ITA members agreed to fund the campaign because “people felt they’d had enough of being demonized” and believed that dermatologists were supporting “an increasing level of misinformation about tanning-bed [bulb] intensity and that tanning causes melanoma, which isn’t true. They [members] are also concerned about the cozy relationship between dermatologists and industry [sunscreen manufacturers].”
ITA’s Executive Director, John Overstreet, stressed that the ITA has in recent years begun urging members to promote “a moderate use message” to consumers. But he acknowledged that the association does not dictate industry behavior and that its members obviously cannot control consumers’ behavior, with regard to where and when and how often they use tanning equipment. “The bottom line is that [industry] detractors say that there’s nothing you can say to adequately warn consumers enough against excessive exposure. Our beef is that both indoor tanning and sunlight [exposure] have both risks and benefits,” Mr. Overstreet says, and ITA members think the latter are under-represented.
“We’re using the vitamin D argument because we’re trying to bridge the cultural conversation that any UV exposure is bad. Somebody has to put this conversation back on a rational plane,” Ms. Longwell said. An estimated 30 million Americans, including 2.3 million teens, tan indoors annually, and about 1 million tan daily, according to recent statistics. Indoor tanning equipment emits UV radiation (UVR), which the Department of Health and Human Services has deemed a known carcinogen.
Cancer Connection?
New York dermatopathologist A. Bernard Ackerman, M.D,. well known for his contrary-to-mainstream views on issues such as melanoma risks of tanning and dermatologists’ relationships with sunscreen product manufacturers, doesn’t exactly applaud the ITA’s new campaign. He does think, however, that a countering view is important regarding cancer risk — particularly melanoma risk — and indoor or outdoor tanning.
Noting that he has no ties, financial or otherwise, to the ITA, Dr. Ackerman says this: “Virtually all of the textbooks say that sunlight is the major cause of basal cell carcinoma, but that evidence is not incontrovertible. And there really is no compelling evidence at all that sunlight causes melanoma; it is simply not convincing. To my knowledge, there has never been a melanoma caused by tanning beds alone.” He cites the fact that melanoma, even in Caucasians, rarely occurs on “exposed” sites, as support for his views.
Addressing the Melanoma- Vitamin D Debates
Some dermatologists who support the sun-exposure and tanning-risk messages the AAD and the Skin Cancer Association have promoted for years — that individuals should avoid mid-day sun, use sunscreen liberally, wear protective clothing, and avoid overexposure to UV radiation — aren’t necessarily willing to push the melanoma-risk issue. That’s in part because of the points Dr. Ackerman makes about the inconclusive evidence.
“It’s true that there hasn’t been any direct, linear link between UV exposure and melanoma,” Dr. Baker says, “but we do know that ultraviolet light is a carcinogen in and of itself. The evidence directly linking UV light damage to basal cell and squamous cell carcinoma is much stronger [than for melanoma], but that’s bad enough. The point is that we don’t have direct links for many things we think it might be in our best interest to avoid.”
The Evidence
Skin cancer cases, estimated at 1 million annually, including 60,000 malignant melanoma cases in 2007, now account for more than half of all malignancies in the United States, according to recent research And the now widely cited statistic that melanoma is implicated in 80% of skin cancer-associated deaths, has put the rare disease on consumers’ radar screens — especially among Caucasians, who are now known to develop the disease at more than 20 times the rate of African Americans. Although available data on tanning-bed bulb strength is conflicting and somewhat confusing, recent research suggests that sunbed UV emission in most equipment in use today is at least five times — and possibly up to 10 times — more potent than natural sunlight.
Sherrif Ibrahim, M.D., Ph.D., in his review article on tanning and cutaneous malignancy, which appeared in the January-February 2008 issue of Dermatologic Surgery, suggests that while the direct, unquestionable link between tanning and increased melanoma risk has yet to be ascertained, the evidence is mounting.
“There is definitely what I would call substantial evidence that excessive exposure to UV from natural or artificial sources increases the risk of developing melanoma,” Dr. Ibrahim, a resident in the Department of Dermatology at the University of Rochester, maintains. “There is a growing cohort [of researchers] who feel . . . a person’s ability to tan, in addition to baseline skin color, is a better predictor for the risk of melanoma with exposure to UVR because this may represent an increased rate of DNA repair. But I think that the tanning industry has attached itself to the melanoma issue because it [the UVR-melanoma link] is the least firmly proven” of the skin cancer types linked to sun and UVR exposure.
“The other issue is that we know melanoma is multi-factorial,” says Dr. Ibrahim, in citing arguments the tanning industry had made when disputing the UVR-melanoma links. Also countering arguments proposed by the tanning industry and some researchers, he points out that, although melanoma rates are increasing exponentially, “better, earlier detection alone cannot account for this change,"
Dr. Ibrahim notes, too, that melanoma is currently the second-most common cancer among women in their 20s, a statistic that has alarmed dermatologists, health officials and, of late, consumers.
The long-term collective data support Dr. Ibrahim’s contention about melanoma’s increase. The U.S. Surveillance, Epidemiology and End Results registry, which includes approximately 14% of the U.S. population, identified malignant melanoma as the most rapidly increasing malignancy between 1973 and 1997 in both men and women. During that 25-year period, age-adjusted melanoma incidence in cases per 100,000 person-years nearly tripled among males, from 6.7 in 1973 to 19.3 in 1997. It more than doubled among females, increasing from 5.9 to 13.8, over the same time period.
Vitamin D
Perhaps even more challenging than the melanoma issue at the moment, for dermatologists who attempt to address patients’ concerns about tanning’s risks and benefits, is the vitamin D debate.
As awareness grows regarding what World Health Organization officials have declared a nearly universal vitamin D deficiency — an estimated 1 billion people worldwide, including more than 40% of elderly Americans and Europeans, lack adequate intake — so too does confusion among consumers. They wonder, understandably, whether they should — or safely can — merely increase their sunlight exposure to bump up production of the important vitamin. They also want to know if it’s a safe, viable alternative to use tanning beds to stimulate vitamin D production, and how much of the vitamin they actually need.
On this point Dr. Ackerman, who has lectured extensively on dermatopathology and clinical dermatology, maintains that the industry’s campaign promoting tanning beds as a source of vitamin D is misguided. “The sun is obviously more beneficial to man than the UV radiation from the bulbs in a tanning bed. The sun is effective in the generation of vitamin D. That’s not the case,” he maintains, “for the bulbs in a tanning bed.”
A recent review paper by Boston University endocrinologist and renowned vitamin D expert Michael Holick, M.D., Ph.D., sheds some light on the subject. (Holick H. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.) Here he suggests that 800 IU is the bare minimum to ward off deficiency-associated conditions such as osteoporosis and reduce risk of cancer and certain chronic diseases. Dr. Holick suggests that individuals who find it difficult to obtain the vitamin from dietary substances turn to supplements or “sensible sun exposure (5 to 30 minutes, depending on the time of day, season, latitude pigmentation) and UVB irradiation” for the recommended dose. Although he cites natural sunlight as the preferred (non-dietary) source of the vitamin, Dr. Holick proposes moderate use of a tanning bed that emits between 2% an 6% UVB, as a secondary source. (He concomitantly advises using sunscreen on the face for those who choose indoor tanning over direct sunlight.)
Despite that data, the primary concern among dermatologists is that the tanning industry is using such research to support the activity’s health benefits, without sufficient balanced information about risks of excessive exposure. And many cite the fact that the most frequent users of indoor tanning equipment are young — under age 30 — and generally, in the United States and Europe, are thus not the individuals who most need increased vitamin D intake.
“I don’t think there’s a dermatologist who would argue with the fact that people need more vitamin D, but the best way to get it is not to go to a tanning booth,” Dr. Ibrahim contends. “You can get plenty of incidental sun exposure walking from the supermarket to your car, and advocating a known carcinogen when completely safe alternatives [foods and supplements] exist, is negligent.”
Dr. Baker concurs, and shares Dr. Ibrahim’s concern that unsavvy patients — especially the young women and teens who comprise the vast majority of indoor tanners — might view the vitamin D-increase recommendations cited by tanning-industry ads as rationale for upping their use of indoor tanning equipment.
“The indoor-tanning industry is not really targeting people my age — those who really do need more vitamin D — or even the dark-skinned individuals who may need more from an external source,” Dr. Baker observes. “The people who usually want to go into the tanning booth are those with fair skin, those who can actually get more vitamin D from small amounts of sun exposure.”
Dr. Spencer, who says he spends “the better part” of his day cutting out his patients’ skin cancers, agrees with Dr. Baker that the ITA campaign and its vitamin D messaging, is unlikely to attract the documented vitamin D-deficient patients.
“Certainly there are a number of people in this country — those in nursing homes, for example — who are vitamin D-deficient. But I don’t see any nursing home patients with their walkers going to indoor tanning parlors,” Dr. Spencer says.
What to Tell Patients
Until the melanoma and vitamin D debates find firmer ground, what should dermatologists tell their patients? The AAD and the American Cancer Society have produced a number of patient information documents on both issues (go to www.aad.org and https://seer.cancer.gov, respectively), which dermatologists might find helpful as a means of bridging discussions.
Dr. Ackerman proposes the moderate-exposure message. “I think we can tell patients that it’s not such a bad thing to get a little sunlight every day,” he says, cautioning that those who are fair-skinned and burn easily should take more precaution and reduce their exposure.
“We’re not saying that people should live totally indoors,” Dr. Baker says. “But I think we should tell our patients to be ‘sun smart’ — to limit their sun exposure during mid-day, to wear protective clothing to keep excessive sun off of their skin, and to use sunscreen when they’re doing water sports. That’s a reasonable message.”
Amid the election-year fracas and continuing controversies about innumerable issues — from global warming to fuel costs, to political scandals and the ongoing Iraq war — another conflict is heating up, so to speak. It’s about tanning and sun exposure, and it’s between the tanning industry and the dermatologist community, the American Academy of Dermatology (AAD) in particular.
A Mixed Message
At issue is a new development in the longstanding debate over health risks associated with indoor tanning. That contentious issue took on a new, more visible dimension in March, when the Indoor Tanning Association (ITA) launched an aggressive multi-message advertising campaign disputing a link between tanning and melanoma, taking dermatologists to task for their connections with sunscreen manufacturers, and urging consumers to “rethink sun bathing” to increase vitamin D intake.
The cornerstone of the Washington, D.C., trade association’s campaign was a full-page print ad headlined “Tanning Causes Melanoma HYPE” (at right) that ran in the New York Times and other major newspapers, and a similarly themed message in a series of television commercials.
“This is an unprecedented campaign in its degree of aggressiveness. And it’s a bit of a smokescreen — nobody goes to a tanning parlor to make vitamin D,” says Tampa, FL, dermatologist and skin cancer specialist James Spencer, M.D., Associate Professor of Clinical Dermatology at the Mount Sinai School of Medicine in New York. “It’s one thing to say that vitamin D is good for you, quite another to say that the dermatologists are dirtballs. That’s scurrilous.” Previous industry campaigns, Dr. Spencer notes, have focused largely on the “cosmetic benefits” of tanning.
Responses
The AAD is currently developing a response to the ITA campaign and the industry’s messages on two newly created Web sites, www.SunlightScam.com and www.trusttanning.com. (In the interim, dermatologists are urged to refer to existing AAD materials and media tool kits, at www.aad.org/members/index.html.)
Why is the campaign so aggressive, and why is it being staged now? Several dermatologists with whom Skin & Aging spoke in mid-April pinned the timing to factors ranging from the increasingly stringent state regulatory environment regarding tanning-bed access by minors, to Congress’ recent passage of the so-called TAN Act (Tanning Accountability and Notification Act).
Among the states pressing for tighter regulation of children’s access to indoor tanning equipment, the Ohio legislature is currently considering a bill that would ban access to minors under age 18. The TAN Act, passed into law last fall, charges the U.S. Food and Drug Administration (FDA) with assessing the current warning label on tanning equipment, to ensure that its positioning and language adequately communicate potential health risks associated with excessive exposure.
“We think the current labeling is inadequate,” says Oregon dermatologist Diane Baker, M.D., Immediate Past President of the AAD Association, because it does not “specifically address skin cancer” risk.
Dr. Baker adds that she suspects the pending FDA actions have contributed somewhat to the tanning association’s campaign timing. But she thinks that the changing state regulatory environment and the industry association’s longstanding dispute with the AAD regarding its position statements on tanning avoidance are larger factors. “We’ve known for a long time that the industry takes exception to the point of view of dermatologists that tanning — specifically indoor tanning — is hazardous to your health and can induce skin cancers over the long term,” she says. “But I think it’s also the fact that dermatologists in several states have become more aggressive,” she adds, about pushing for stricter tanning-equipment use regulation and more specific health-risk warning wording.
“Over the years, various states have been chipping away at their [tanning salons] business, with more restrictive legislation regarding children — and you have to remember,” Dr. Spencer observes, “that high school cheerleaders and young women are a a big part of their business. They’re cash customers.” At present, 25 states have enacted age restrictions, including a handful that have added absolute age restrictions, ranging from 13 to 16 on tanning. Increasingly, states are moving toward requiring parental consent (in writing or by their on-site presence) for teens to use tanning facilities.
The ITA’s New Approach
On her first point about the tanning industry’s taking issue with dermatologists’ UV-exposure messages, Dr. Baker is correct, according to Indoor Tanning Association officials. ITA’s Commun-ications Director Sarah Longwell told Skin & Aging that ITA members agreed to fund the campaign because “people felt they’d had enough of being demonized” and believed that dermatologists were supporting “an increasing level of misinformation about tanning-bed [bulb] intensity and that tanning causes melanoma, which isn’t true. They [members] are also concerned about the cozy relationship between dermatologists and industry [sunscreen manufacturers].”
ITA’s Executive Director, John Overstreet, stressed that the ITA has in recent years begun urging members to promote “a moderate use message” to consumers. But he acknowledged that the association does not dictate industry behavior and that its members obviously cannot control consumers’ behavior, with regard to where and when and how often they use tanning equipment. “The bottom line is that [industry] detractors say that there’s nothing you can say to adequately warn consumers enough against excessive exposure. Our beef is that both indoor tanning and sunlight [exposure] have both risks and benefits,” Mr. Overstreet says, and ITA members think the latter are under-represented.
“We’re using the vitamin D argument because we’re trying to bridge the cultural conversation that any UV exposure is bad. Somebody has to put this conversation back on a rational plane,” Ms. Longwell said. An estimated 30 million Americans, including 2.3 million teens, tan indoors annually, and about 1 million tan daily, according to recent statistics. Indoor tanning equipment emits UV radiation (UVR), which the Department of Health and Human Services has deemed a known carcinogen.
Cancer Connection?
New York dermatopathologist A. Bernard Ackerman, M.D,. well known for his contrary-to-mainstream views on issues such as melanoma risks of tanning and dermatologists’ relationships with sunscreen product manufacturers, doesn’t exactly applaud the ITA’s new campaign. He does think, however, that a countering view is important regarding cancer risk — particularly melanoma risk — and indoor or outdoor tanning.
Noting that he has no ties, financial or otherwise, to the ITA, Dr. Ackerman says this: “Virtually all of the textbooks say that sunlight is the major cause of basal cell carcinoma, but that evidence is not incontrovertible. And there really is no compelling evidence at all that sunlight causes melanoma; it is simply not convincing. To my knowledge, there has never been a melanoma caused by tanning beds alone.” He cites the fact that melanoma, even in Caucasians, rarely occurs on “exposed” sites, as support for his views.
Addressing the Melanoma- Vitamin D Debates
Some dermatologists who support the sun-exposure and tanning-risk messages the AAD and the Skin Cancer Association have promoted for years — that individuals should avoid mid-day sun, use sunscreen liberally, wear protective clothing, and avoid overexposure to UV radiation — aren’t necessarily willing to push the melanoma-risk issue. That’s in part because of the points Dr. Ackerman makes about the inconclusive evidence.
“It’s true that there hasn’t been any direct, linear link between UV exposure and melanoma,” Dr. Baker says, “but we do know that ultraviolet light is a carcinogen in and of itself. The evidence directly linking UV light damage to basal cell and squamous cell carcinoma is much stronger [than for melanoma], but that’s bad enough. The point is that we don’t have direct links for many things we think it might be in our best interest to avoid.”
The Evidence
Skin cancer cases, estimated at 1 million annually, including 60,000 malignant melanoma cases in 2007, now account for more than half of all malignancies in the United States, according to recent research And the now widely cited statistic that melanoma is implicated in 80% of skin cancer-associated deaths, has put the rare disease on consumers’ radar screens — especially among Caucasians, who are now known to develop the disease at more than 20 times the rate of African Americans. Although available data on tanning-bed bulb strength is conflicting and somewhat confusing, recent research suggests that sunbed UV emission in most equipment in use today is at least five times — and possibly up to 10 times — more potent than natural sunlight.
Sherrif Ibrahim, M.D., Ph.D., in his review article on tanning and cutaneous malignancy, which appeared in the January-February 2008 issue of Dermatologic Surgery, suggests that while the direct, unquestionable link between tanning and increased melanoma risk has yet to be ascertained, the evidence is mounting.
“There is definitely what I would call substantial evidence that excessive exposure to UV from natural or artificial sources increases the risk of developing melanoma,” Dr. Ibrahim, a resident in the Department of Dermatology at the University of Rochester, maintains. “There is a growing cohort [of researchers] who feel . . . a person’s ability to tan, in addition to baseline skin color, is a better predictor for the risk of melanoma with exposure to UVR because this may represent an increased rate of DNA repair. But I think that the tanning industry has attached itself to the melanoma issue because it [the UVR-melanoma link] is the least firmly proven” of the skin cancer types linked to sun and UVR exposure.
“The other issue is that we know melanoma is multi-factorial,” says Dr. Ibrahim, in citing arguments the tanning industry had made when disputing the UVR-melanoma links. Also countering arguments proposed by the tanning industry and some researchers, he points out that, although melanoma rates are increasing exponentially, “better, earlier detection alone cannot account for this change,"
Dr. Ibrahim notes, too, that melanoma is currently the second-most common cancer among women in their 20s, a statistic that has alarmed dermatologists, health officials and, of late, consumers.
The long-term collective data support Dr. Ibrahim’s contention about melanoma’s increase. The U.S. Surveillance, Epidemiology and End Results registry, which includes approximately 14% of the U.S. population, identified malignant melanoma as the most rapidly increasing malignancy between 1973 and 1997 in both men and women. During that 25-year period, age-adjusted melanoma incidence in cases per 100,000 person-years nearly tripled among males, from 6.7 in 1973 to 19.3 in 1997. It more than doubled among females, increasing from 5.9 to 13.8, over the same time period.
Vitamin D
Perhaps even more challenging than the melanoma issue at the moment, for dermatologists who attempt to address patients’ concerns about tanning’s risks and benefits, is the vitamin D debate.
As awareness grows regarding what World Health Organization officials have declared a nearly universal vitamin D deficiency — an estimated 1 billion people worldwide, including more than 40% of elderly Americans and Europeans, lack adequate intake — so too does confusion among consumers. They wonder, understandably, whether they should — or safely can — merely increase their sunlight exposure to bump up production of the important vitamin. They also want to know if it’s a safe, viable alternative to use tanning beds to stimulate vitamin D production, and how much of the vitamin they actually need.
On this point Dr. Ackerman, who has lectured extensively on dermatopathology and clinical dermatology, maintains that the industry’s campaign promoting tanning beds as a source of vitamin D is misguided. “The sun is obviously more beneficial to man than the UV radiation from the bulbs in a tanning bed. The sun is effective in the generation of vitamin D. That’s not the case,” he maintains, “for the bulbs in a tanning bed.”
A recent review paper by Boston University endocrinologist and renowned vitamin D expert Michael Holick, M.D., Ph.D., sheds some light on the subject. (Holick H. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.) Here he suggests that 800 IU is the bare minimum to ward off deficiency-associated conditions such as osteoporosis and reduce risk of cancer and certain chronic diseases. Dr. Holick suggests that individuals who find it difficult to obtain the vitamin from dietary substances turn to supplements or “sensible sun exposure (5 to 30 minutes, depending on the time of day, season, latitude pigmentation) and UVB irradiation” for the recommended dose. Although he cites natural sunlight as the preferred (non-dietary) source of the vitamin, Dr. Holick proposes moderate use of a tanning bed that emits between 2% an 6% UVB, as a secondary source. (He concomitantly advises using sunscreen on the face for those who choose indoor tanning over direct sunlight.)
Despite that data, the primary concern among dermatologists is that the tanning industry is using such research to support the activity’s health benefits, without sufficient balanced information about risks of excessive exposure. And many cite the fact that the most frequent users of indoor tanning equipment are young — under age 30 — and generally, in the United States and Europe, are thus not the individuals who most need increased vitamin D intake.
“I don’t think there’s a dermatologist who would argue with the fact that people need more vitamin D, but the best way to get it is not to go to a tanning booth,” Dr. Ibrahim contends. “You can get plenty of incidental sun exposure walking from the supermarket to your car, and advocating a known carcinogen when completely safe alternatives [foods and supplements] exist, is negligent.”
Dr. Baker concurs, and shares Dr. Ibrahim’s concern that unsavvy patients — especially the young women and teens who comprise the vast majority of indoor tanners — might view the vitamin D-increase recommendations cited by tanning-industry ads as rationale for upping their use of indoor tanning equipment.
“The indoor-tanning industry is not really targeting people my age — those who really do need more vitamin D — or even the dark-skinned individuals who may need more from an external source,” Dr. Baker observes. “The people who usually want to go into the tanning booth are those with fair skin, those who can actually get more vitamin D from small amounts of sun exposure.”
Dr. Spencer, who says he spends “the better part” of his day cutting out his patients’ skin cancers, agrees with Dr. Baker that the ITA campaign and its vitamin D messaging, is unlikely to attract the documented vitamin D-deficient patients.
“Certainly there are a number of people in this country — those in nursing homes, for example — who are vitamin D-deficient. But I don’t see any nursing home patients with their walkers going to indoor tanning parlors,” Dr. Spencer says.
What to Tell Patients
Until the melanoma and vitamin D debates find firmer ground, what should dermatologists tell their patients? The AAD and the American Cancer Society have produced a number of patient information documents on both issues (go to www.aad.org and https://seer.cancer.gov, respectively), which dermatologists might find helpful as a means of bridging discussions.
Dr. Ackerman proposes the moderate-exposure message. “I think we can tell patients that it’s not such a bad thing to get a little sunlight every day,” he says, cautioning that those who are fair-skinned and burn easily should take more precaution and reduce their exposure.
“We’re not saying that people should live totally indoors,” Dr. Baker says. “But I think we should tell our patients to be ‘sun smart’ — to limit their sun exposure during mid-day, to wear protective clothing to keep excessive sun off of their skin, and to use sunscreen when they’re doing water sports. That’s a reasonable message.”
Amid the election-year fracas and continuing controversies about innumerable issues — from global warming to fuel costs, to political scandals and the ongoing Iraq war — another conflict is heating up, so to speak. It’s about tanning and sun exposure, and it’s between the tanning industry and the dermatologist community, the American Academy of Dermatology (AAD) in particular.
A Mixed Message
At issue is a new development in the longstanding debate over health risks associated with indoor tanning. That contentious issue took on a new, more visible dimension in March, when the Indoor Tanning Association (ITA) launched an aggressive multi-message advertising campaign disputing a link between tanning and melanoma, taking dermatologists to task for their connections with sunscreen manufacturers, and urging consumers to “rethink sun bathing” to increase vitamin D intake.
The cornerstone of the Washington, D.C., trade association’s campaign was a full-page print ad headlined “Tanning Causes Melanoma HYPE” (at right) that ran in the New York Times and other major newspapers, and a similarly themed message in a series of television commercials.
“This is an unprecedented campaign in its degree of aggressiveness. And it’s a bit of a smokescreen — nobody goes to a tanning parlor to make vitamin D,” says Tampa, FL, dermatologist and skin cancer specialist James Spencer, M.D., Associate Professor of Clinical Dermatology at the Mount Sinai School of Medicine in New York. “It’s one thing to say that vitamin D is good for you, quite another to say that the dermatologists are dirtballs. That’s scurrilous.” Previous industry campaigns, Dr. Spencer notes, have focused largely on the “cosmetic benefits” of tanning.
Responses
The AAD is currently developing a response to the ITA campaign and the industry’s messages on two newly created Web sites, www.SunlightScam.com and www.trusttanning.com. (In the interim, dermatologists are urged to refer to existing AAD materials and media tool kits, at www.aad.org/members/index.html.)
Why is the campaign so aggressive, and why is it being staged now? Several dermatologists with whom Skin & Aging spoke in mid-April pinned the timing to factors ranging from the increasingly stringent state regulatory environment regarding tanning-bed access by minors, to Congress’ recent passage of the so-called TAN Act (Tanning Accountability and Notification Act).
Among the states pressing for tighter regulation of children’s access to indoor tanning equipment, the Ohio legislature is currently considering a bill that would ban access to minors under age 18. The TAN Act, passed into law last fall, charges the U.S. Food and Drug Administration (FDA) with assessing the current warning label on tanning equipment, to ensure that its positioning and language adequately communicate potential health risks associated with excessive exposure.
“We think the current labeling is inadequate,” says Oregon dermatologist Diane Baker, M.D., Immediate Past President of the AAD Association, because it does not “specifically address skin cancer” risk.
Dr. Baker adds that she suspects the pending FDA actions have contributed somewhat to the tanning association’s campaign timing. But she thinks that the changing state regulatory environment and the industry association’s longstanding dispute with the AAD regarding its position statements on tanning avoidance are larger factors. “We’ve known for a long time that the industry takes exception to the point of view of dermatologists that tanning — specifically indoor tanning — is hazardous to your health and can induce skin cancers over the long term,” she says. “But I think it’s also the fact that dermatologists in several states have become more aggressive,” she adds, about pushing for stricter tanning-equipment use regulation and more specific health-risk warning wording.
“Over the years, various states have been chipping away at their [tanning salons] business, with more restrictive legislation regarding children — and you have to remember,” Dr. Spencer observes, “that high school cheerleaders and young women are a a big part of their business. They’re cash customers.” At present, 25 states have enacted age restrictions, including a handful that have added absolute age restrictions, ranging from 13 to 16 on tanning. Increasingly, states are moving toward requiring parental consent (in writing or by their on-site presence) for teens to use tanning facilities.
The ITA’s New Approach
On her first point about the tanning industry’s taking issue with dermatologists’ UV-exposure messages, Dr. Baker is correct, according to Indoor Tanning Association officials. ITA’s Commun-ications Director Sarah Longwell told Skin & Aging that ITA members agreed to fund the campaign because “people felt they’d had enough of being demonized” and believed that dermatologists were supporting “an increasing level of misinformation about tanning-bed [bulb] intensity and that tanning causes melanoma, which isn’t true. They [members] are also concerned about the cozy relationship between dermatologists and industry [sunscreen manufacturers].”
ITA’s Executive Director, John Overstreet, stressed that the ITA has in recent years begun urging members to promote “a moderate use message” to consumers. But he acknowledged that the association does not dictate industry behavior and that its members obviously cannot control consumers’ behavior, with regard to where and when and how often they use tanning equipment. “The bottom line is that [industry] detractors say that there’s nothing you can say to adequately warn consumers enough against excessive exposure. Our beef is that both indoor tanning and sunlight [exposure] have both risks and benefits,” Mr. Overstreet says, and ITA members think the latter are under-represented.
“We’re using the vitamin D argument because we’re trying to bridge the cultural conversation that any UV exposure is bad. Somebody has to put this conversation back on a rational plane,” Ms. Longwell said. An estimated 30 million Americans, including 2.3 million teens, tan indoors annually, and about 1 million tan daily, according to recent statistics. Indoor tanning equipment emits UV radiation (UVR), which the Department of Health and Human Services has deemed a known carcinogen.
Cancer Connection?
New York dermatopathologist A. Bernard Ackerman, M.D,. well known for his contrary-to-mainstream views on issues such as melanoma risks of tanning and dermatologists’ relationships with sunscreen product manufacturers, doesn’t exactly applaud the ITA’s new campaign. He does think, however, that a countering view is important regarding cancer risk — particularly melanoma risk — and indoor or outdoor tanning.
Noting that he has no ties, financial or otherwise, to the ITA, Dr. Ackerman says this: “Virtually all of the textbooks say that sunlight is the major cause of basal cell carcinoma, but that evidence is not incontrovertible. And there really is no compelling evidence at all that sunlight causes melanoma; it is simply not convincing. To my knowledge, there has never been a melanoma caused by tanning beds alone.” He cites the fact that melanoma, even in Caucasians, rarely occurs on “exposed” sites, as support for his views.
Addressing the Melanoma- Vitamin D Debates
Some dermatologists who support the sun-exposure and tanning-risk messages the AAD and the Skin Cancer Association have promoted for years — that individuals should avoid mid-day sun, use sunscreen liberally, wear protective clothing, and avoid overexposure to UV radiation — aren’t necessarily willing to push the melanoma-risk issue. That’s in part because of the points Dr. Ackerman makes about the inconclusive evidence.
“It’s true that there hasn’t been any direct, linear link between UV exposure and melanoma,” Dr. Baker says, “but we do know that ultraviolet light is a carcinogen in and of itself. The evidence directly linking UV light damage to basal cell and squamous cell carcinoma is much stronger [than for melanoma], but that’s bad enough. The point is that we don’t have direct links for many things we think it might be in our best interest to avoid.”
The Evidence
Skin cancer cases, estimated at 1 million annually, including 60,000 malignant melanoma cases in 2007, now account for more than half of all malignancies in the United States, according to recent research And the now widely cited statistic that melanoma is implicated in 80% of skin cancer-associated deaths, has put the rare disease on consumers’ radar screens — especially among Caucasians, who are now known to develop the disease at more than 20 times the rate of African Americans. Although available data on tanning-bed bulb strength is conflicting and somewhat confusing, recent research suggests that sunbed UV emission in most equipment in use today is at least five times — and possibly up to 10 times — more potent than natural sunlight.
Sherrif Ibrahim, M.D., Ph.D., in his review article on tanning and cutaneous malignancy, which appeared in the January-February 2008 issue of Dermatologic Surgery, suggests that while the direct, unquestionable link between tanning and increased melanoma risk has yet to be ascertained, the evidence is mounting.
“There is definitely what I would call substantial evidence that excessive exposure to UV from natural or artificial sources increases the risk of developing melanoma,” Dr. Ibrahim, a resident in the Department of Dermatology at the University of Rochester, maintains. “There is a growing cohort [of researchers] who feel . . . a person’s ability to tan, in addition to baseline skin color, is a better predictor for the risk of melanoma with exposure to UVR because this may represent an increased rate of DNA repair. But I think that the tanning industry has attached itself to the melanoma issue because it [the UVR-melanoma link] is the least firmly proven” of the skin cancer types linked to sun and UVR exposure.
“The other issue is that we know melanoma is multi-factorial,” says Dr. Ibrahim, in citing arguments the tanning industry had made when disputing the UVR-melanoma links. Also countering arguments proposed by the tanning industry and some researchers, he points out that, although melanoma rates are increasing exponentially, “better, earlier detection alone cannot account for this change,"
Dr. Ibrahim notes, too, that melanoma is currently the second-most common cancer among women in their 20s, a statistic that has alarmed dermatologists, health officials and, of late, consumers.
The long-term collective data support Dr. Ibrahim’s contention about melanoma’s increase. The U.S. Surveillance, Epidemiology and End Results registry, which includes approximately 14% of the U.S. population, identified malignant melanoma as the most rapidly increasing malignancy between 1973 and 1997 in both men and women. During that 25-year period, age-adjusted melanoma incidence in cases per 100,000 person-years nearly tripled among males, from 6.7 in 1973 to 19.3 in 1997. It more than doubled among females, increasing from 5.9 to 13.8, over the same time period.
Vitamin D
Perhaps even more challenging than the melanoma issue at the moment, for dermatologists who attempt to address patients’ concerns about tanning’s risks and benefits, is the vitamin D debate.
As awareness grows regarding what World Health Organization officials have declared a nearly universal vitamin D deficiency — an estimated 1 billion people worldwide, including more than 40% of elderly Americans and Europeans, lack adequate intake — so too does confusion among consumers. They wonder, understandably, whether they should — or safely can — merely increase their sunlight exposure to bump up production of the important vitamin. They also want to know if it’s a safe, viable alternative to use tanning beds to stimulate vitamin D production, and how much of the vitamin they actually need.
On this point Dr. Ackerman, who has lectured extensively on dermatopathology and clinical dermatology, maintains that the industry’s campaign promoting tanning beds as a source of vitamin D is misguided. “The sun is obviously more beneficial to man than the UV radiation from the bulbs in a tanning bed. The sun is effective in the generation of vitamin D. That’s not the case,” he maintains, “for the bulbs in a tanning bed.”
A recent review paper by Boston University endocrinologist and renowned vitamin D expert Michael Holick, M.D., Ph.D., sheds some light on the subject. (Holick H. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.) Here he suggests that 800 IU is the bare minimum to ward off deficiency-associated conditions such as osteoporosis and reduce risk of cancer and certain chronic diseases. Dr. Holick suggests that individuals who find it difficult to obtain the vitamin from dietary substances turn to supplements or “sensible sun exposure (5 to 30 minutes, depending on the time of day, season, latitude pigmentation) and UVB irradiation” for the recommended dose. Although he cites natural sunlight as the preferred (non-dietary) source of the vitamin, Dr. Holick proposes moderate use of a tanning bed that emits between 2% an 6% UVB, as a secondary source. (He concomitantly advises using sunscreen on the face for those who choose indoor tanning over direct sunlight.)
Despite that data, the primary concern among dermatologists is that the tanning industry is using such research to support the activity’s health benefits, without sufficient balanced information about risks of excessive exposure. And many cite the fact that the most frequent users of indoor tanning equipment are young — under age 30 — and generally, in the United States and Europe, are thus not the individuals who most need increased vitamin D intake.
“I don’t think there’s a dermatologist who would argue with the fact that people need more vitamin D, but the best way to get it is not to go to a tanning booth,” Dr. Ibrahim contends. “You can get plenty of incidental sun exposure walking from the supermarket to your car, and advocating a known carcinogen when completely safe alternatives [foods and supplements] exist, is negligent.”
Dr. Baker concurs, and shares Dr. Ibrahim’s concern that unsavvy patients — especially the young women and teens who comprise the vast majority of indoor tanners — might view the vitamin D-increase recommendations cited by tanning-industry ads as rationale for upping their use of indoor tanning equipment.
“The indoor-tanning industry is not really targeting people my age — those who really do need more vitamin D — or even the dark-skinned individuals who may need more from an external source,” Dr. Baker observes. “The people who usually want to go into the tanning booth are those with fair skin, those who can actually get more vitamin D from small amounts of sun exposure.”
Dr. Spencer, who says he spends “the better part” of his day cutting out his patients’ skin cancers, agrees with Dr. Baker that the ITA campaign and its vitamin D messaging, is unlikely to attract the documented vitamin D-deficient patients.
“Certainly there are a number of people in this country — those in nursing homes, for example — who are vitamin D-deficient. But I don’t see any nursing home patients with their walkers going to indoor tanning parlors,” Dr. Spencer says.
What to Tell Patients
Until the melanoma and vitamin D debates find firmer ground, what should dermatologists tell their patients? The AAD and the American Cancer Society have produced a number of patient information documents on both issues (go to www.aad.org and https://seer.cancer.gov, respectively), which dermatologists might find helpful as a means of bridging discussions.
Dr. Ackerman proposes the moderate-exposure message. “I think we can tell patients that it’s not such a bad thing to get a little sunlight every day,” he says, cautioning that those who are fair-skinned and burn easily should take more precaution and reduce their exposure.
“We’re not saying that people should live totally indoors,” Dr. Baker says. “But I think we should tell our patients to be ‘sun smart’ — to limit their sun exposure during mid-day, to wear protective clothing to keep excessive sun off of their skin, and to use sunscreen when they’re doing water sports. That’s a reasonable message.”
