Spatial Distribution of Businesses Offering UV Tanning Across 7 U.S. Metro Areas

1. Spatial Distribution of Businesses Offering UV Tanning Across 7 U.S. Metro Areas S. Bryn Austin, Longxiang Li, Allegra R. Gordon, Jeffrey Blossom, Alan Geller, Caterina Stamoulis Boston Children’s Hospital Harvard T.H. Chan School of Public Health Harvard Center for Geographic Analysis

2. Presenter Disclosures S. Bryn Austin No relationships to disclose The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

3. Acknowledgments Research supported by Boston Children’s Hospital Pediatric Associates Pilot Research Program

4. Background: Societal Appearance Ideals Harmful • Strong pressure to modify one’s appearance to avoid stigma, discrimination • Pervade all sectors of society • Education, employment, healthcare, social relationships (Austin et al 2013; Puhl & King 2013; Thompson et al 1999)

5. Background: Societal Ideals Fuel Profits, Gender Disparities • Industries profit from appearance ideals • UV indoor tanning industry prime example • Also vast cosmetic procedures industry (Austin et al 2013; Puhl & King 2013; Thompson et al 1999)

6. Background: Societal Ideals Fuel Profits, Gender Disparities • Industries profit from appearance ideals • UV indoor tanning industry prime example • Also vast cosmetic procedures industry • Disparate burden by gender • Young white women make up the largest subset of consumer base for UV tanning (Austin et al 2013; Puhl & King 2013; CDC 2012; Thompson et al 1999)

7. Background on UV Tanning Industry • Business volume, revenue enormous • Annually in US> $2.9b spent on UV tanning (Choi et al 2010; CDC 2012; Modvay 2012)

8. Background on UV Tanning Industry • Business volume, revenue enormous • Annually in US> $2.9b spent on UV tanning • Millions of Americans UV tan • In 2010, 5.6% of adults used UV indoor tanning in past year • ~15 million people • 1/3 of white women 18-24 y.o. (Choi et al 2010; CDC 2012; Modvay 2012)

9. Signs of Impact of State-Level Advocacy, ACA Taxes • Public health advances in recent years • State-level restrictions on youth indoor tanning • Affordable Care Act: 10% tax on tanning salons (Guy et al 2017; CDC 2012; Modvay 2012; Choi et al 2010)

10. Signs of Impact of State-Level Advocacy, ACA Taxes • Public health advances in recent years • State-level restrictions on youth indoor tanning • Affordable Care Act: 10% tax on tanning salons • Evidence of drop in past-year prevalence • Among all youth, 16% in 2009 7% in 2015 • Among white girls, 37% in 2009 15% in 2015 (Guy et al 2017; CDC 2012; Modvay 2012; Choi et al 2010)

11. Signs of Impact of State-Level Advocacy, ACA Taxes • Public health advances in recent years • State-level restrictions on youth indoor tanning • Affordable Care Act: 10% tax on tanning salons • Evidence of drop in past-year prevalence • Among all youth, 16% in 2009 7% in 2015 • Among white girls, 37% in 2009 15% in 2015 • GOP tried to kill tax on UV tan in ACA repeal (Guy et al 2017; CDC 2012; Modvay 2012; Choi et al 2010)

12. Background: Skin Cancer Risk of UV Indoor Tanning • Melanoma risk > doubled in frequent users • Among melanoma patients < 30 years old, attributable risk of UV tanning ~ 76% • Sharper rise in melanoma incidence in women than men since becoming popular in 1980s (Boniol et al 2012; Dore et al 2012; Cust et al 2011; Coelho et al 2009)

13. Background: UV Indoor Tanning in Wide Range of Businesses • Anecdotal evidence moving out of salons • UV tanning beds infiltrating in wide variety of settings (e.g, gyms, spas) • May be more prevalent in some cities

14. Background: UV Indoor Tanning in Wide Range of Businesses • Infiltration beyond tanning salons, high concentration in metro areas may signal…

15. Background: UV Indoor Tanning in Wide Range of Businesses • Infiltration beyond tanning salons, high concentration in metro areas may signal… • Increased exposure of consumers • Normalization of toxic procedure • Deceptive associations w/ health • i.e., when offered in gyms

16. Background: UV Indoor Tanning in Wide Range of Businesses • Infiltration beyond tanning salons, high concentration in metro areas may signal… • Increased exposure of consumers • Normalization of toxic procedure • Deceptive associations w/ health • i.e., when offered in gyms • Yet no systematic data available

17. Study Objectives • Build predictive models of probability of businesses offering UV tanning • Generate predictive maps of spatial distribution of businesses in 7 US metro areas

18. Beauty Map Study • Info Group US business database, 2014-15 • We restricted to 7 metro areas: Boston, Chicago, Dallas, Los Angeles, Miami, New York, Seattle

19. Beauty Map Study • Info Group US business database, 2014-15 • Restricted to 69 industry codes found in pilot study to offer UV tanning/cosmetic procedures • e.g., gyms, health clubs, tattoo-removal & laser-treatment centers, massage parlors, hair/nail salons, spas, dentists, dermatologists, medical centers, tanning salons (Austin et al 2013)

20. Beauty Map Study: Brief Phone Interview • Info Group business call center did phone interviews w/ businesses • Conducted in Nov 2014, Nov 2015 • Stratified random sample selected for calls • 2014: 80,002 w/ 31% response rate: N=24,012 • 2015: 80,010 w/ 30% response rate: N=23,308 • Note: Some businesses in both waves

21. Beauty Map Study:Brief Phone Interview • Interviews included verification of: • Business type, location, provision of UV tan • Do you offer UV or spray tanning? • Yes – both • Yes – UV only • Yes – spray only • No – neither • Unknown • Refused

22. Additional Data Sources • US Census, 2010 • Resident demographics by block group (e.g., race/ethnicity, education)

23. Additional Data Sources • US Census, 2010 • Resident demographics by block group (e.g., race/ethnicity, education) • National Land Cover Database, 2011 • Density of development by block group

24. Additional Data Sources • US Census, 2010 • Resident demographics by block group (e.g., race/ethnicity, education) • National Land Cover Database, 2011 • Density of development by block group • ESRI Business Analyst, 2015 • Identified all businesses in 7 metros classified w/ industry codes from Beauty Map Study

25. Data Analysis Step 1:Probability Business Offers UV Tan • Multivariable GLM model • Unit of analysis: Business (from Beauty Map Study) • N=21,432 businesses • Dependent variable: UV tanning offered (yes/no) • Independent variables: industry code, metro area, block group characteristics: # white population, # population w/ college degree, development density • Data sources: Beauty Map Study, US Census, National Land Cover Database

26. Data Analysis Step 2: Generate Data for Predictive Maps • Multivariable GLM model • Unit of analysis: Business (from ESRI database) • N=82,846 businesses • Purpose: Use Step 1 estimates from Beauty Map Study to predict probability businesses in ESRI database offer UV tanning • Data sources: Beauty Map Study, US Census, National Land Cover Database, ESRI Business Analyst

27. Data Analysis Step 3: Aggregate Data in Block Groups • Aggregate results from Step 2 at block- group level in 7 metro areas • For each block group, assign estimate of probability of presence of at least one business offering UV tan • Range from 0 to 1.0 • Create maps shaded at block-group level to represent probability

28. % Beauty Map Study Businesses Offering UV Tanning, by Metro Area Chicago Boston Seattle 10% Metro Area: 8% 8% 7% 6% Percent 4% 4% Metro Area

29. % Gyms, Health Clubs in Beauty Map Study Offering UV Tanning, by Metro Area Chicago Boston New York 18% 15% 15% Metro Area: 11% Percent 9% 8% 7% Metro Area

30. GLM Model Results: Probability of Business Offering UV Tanning • Higher probability associated with:

31. GLM Model Results: Probability of Business Offering UV Tanning • Higher probability associated with: • Business types: Tanning salons, spas, health clubs, gyms, dermatologists

32. GLM Model Results: Probability of Business Offering UV Tanning • Higher probability associated with: • Business types: Tanning salons, spas, health clubs, gyms, dermatologists • Higher # white residents, lower # residents w/ college degree, higher density development in block group

33. GLM Model Results: Probability of Business Offering UV Tanning • Higher probability associated with: • Business types: Tanning salons, spas, health clubs, gyms, dermatologists • Higher # white residents, lower # residents w/ college degree, higher density development in block group • Located in Boston, New York

34. GLM Model Results: Probability of Business Offering UV Tanning • Higher probability associated with: • Business types: Tanning salons, spas, health clubs, gyms, dermatologists • Higher # white residents, lower # residents w/ college degree, higher density development in block group • Located in Boston, New York • Lower probability associated with: • Business types: Massage therapists, recreation centers • Located in Dallas, Los Angeles, Miami

35. Los Angeles Metro Area Note: Darker shading = higher probability block group has at least one business w/ UV tanning

36. Boston Metro Area Note: Darker shading = higher probability block group has at least one business w/ UV tanning

37. Summary: Predictors of UV Tanning Sites • UV tanning more likely to be sited in: • Businesses marketing health (e.g., gyms, dermatologists) and beauty/prestige (e.g., spas)

38. Summary: Predictors of UV Tanning Sites • UV tanning more likely to be sited in: • Businesses marketing health (e.g., gyms, dermatologists) and beauty/prestige (e.g., spas) • Neighborhoods with higher white population, fewer college educated residents

39. Summary: Predictors of UV Tanning Sites • UV tanning more likely to be sited in: • Businesses marketing health (e.g., gyms, dermatologists) and beauty/prestige (e.g., spas) • Neighborhoods with higher white population, fewer college educated residents • Sunbelt metro areas less likely to have UV tanning offered in businesses

40. Limitations • Completed surveys from ~ 30% businesses selected for inclusion • Self report from staff answering phone • Demographic patterns of neighborhoods, not of individual consumers • However, residents where UV tanning located likely exposed to storefront signage/marketing

41. Limitations • Cross-sectional analyses, but industry in flux • Industry facing major headwinds w/ increasing state regulations, Affordable Care Act taxes • Longitudinal analyses needed to track changes over time w/ public health gains or losses

42. Strengths • To our knowledge, first large-scale, systematic study of U.S. businesses to: • Assess range of business types to offer UV tan • Generate predictive maps of UV tanning sites in major metros across most regions of country

43. Strengths • To our knowledge, first large-scale, systematic study of U.S. businesses to: • Assess range of business types to offer UV tan • Generate predictive maps of UV tanning sites in major metros across most regions of country • Baseline data to track change over time in businesses offering UV indoor tanning

44. Implications • Carcinogenic procedure in consumer settings serving tens of millions daily

45. Implications • Carcinogenic procedure in consumer settings serving tens of millions daily • Ubiquitous exposure of consumers • Normalization of: • Toxic procedure • Stigmatizing appearance ideals, esp. for women • Deceptive associations w/ health • i.e., when offered in gyms, dermatology centers

46. Need for Continued Advocacy • Challenge UV tanning industry’s exploitation of pernicious societal appearance ideals • Especially for women, youth

47. Need for Continued Advocacy • Challenge UV tanning industry’s exploitation of pernicious societal appearance ideals • Especially for women, youth • Increase efforts to limit, ban UV tanning • Increase # states that ban for minors • Gyms in particular should be targeted for promoting deceptive associations w/ health

48. Thank you