SUN SAFETY: Health Impacts of Tanning & Local Boards of Health

1. SUN SAFETY:Health Impacts of Tanning & Local Boards of Health MHOA Educational Meeting June 20, 2013

2. Tanning Facilities: Health Issues and Regulations Beverly E. Anderson, MPH, RS Interim Director, Radiation Control Program Bureau of Environmental Health Massachusetts Department of Public Health beverly.anderson@state.ma.us Ruth M. Price, MPH, MEd, CHES Program Manager, Regional Sun Safety Program Town of Danvers, Host Organization North Shore Community Health Network rprice@mail.danvers-ma.org

3. Learning Objectives • Learn about the Regional Public Health Initiative: Sun Safety Program. • Understand the factors contributing to skin cancer. • Define UV radiation and the effects of UV exposure. • Gain a deeper understanding of the tanning industry and public health implications. • Demonstrate inspection tools, enforcement strategies and recommendations. • Discuss present and future indoor tanning regulations and the science behind restrictions among youth.

4. Learning Objective #1 Overview of the Regional Public Health Initiative: Sun Safety Program

5. Regional Public Health Initiative • Regional public health demonstration project • Purpose to strengthen the capacity of local public health to work collaboratively to provide communities with health protection, promotion and prevention efforts • 3+ Year Initiative • History, Funding, Concept Mapping & Needs Assessment • Program Design & Structure • Implementation, Outputs & Evaluation • Next Steps

6. Program Funding

7. 18 Collaborating Communities • Beverly • Danvers* • Essex • Gloucester • Hamilton • Ipswich • Lynn • Lynnfield • Manchester-by-the-Sea * Fiscal Host • Marblehead • Nahant • Peabody • Salem • Saugus • Swampscott • Topsfield • Wenham • Rockport

8. 2. Building Regional Capacity 5. Environmental Health 4. Wellness Promotion and Prevention 1. Vulnerable Populations 3. Youth/Adolescent Issues Concept Mapping Results Concept Mapping: A method of planning that summarizes and reflects how an entire group views a topic using different graphical displays.

9. Feasibility & Importance Rating: Go-Zone Chart Findings suggested: • Building the capacity of the local health departments to work regionally • Tackle wellness issue(s) that can be addressed across the region

10. Sun Safety Program:Structure & Operations • Program Operations • Program Manager 19°/week • Hosted by Town of Danvers • Supervision from Danvers Pubic Health Director • $50,000 Annual Budget • Shared office space with Danvers Public Health Nurse • Laptop, mobile phone and transportation • Website • Work plan NS CHN Steering Committee Sun Safety Steering Committee Sun Safety Program Manager

11. Sun Safety Program Goals • To reduce skin cancer/ melanoma rates on the North Shore and Cape Ann Area • To strengthen the capacity of local public health to work more collaboratively

12. Sun Safety Program Objectives • To strengthen policies and regulations regarding limiting exposure to indoor and outdoor UV (ultraviolet rays). • To increase educational programs and awareness regarding skin cancer prevention and detection with the outcome of reducing preventable deaths. • To encourage the use of proper skin protection and access to shade. • To promote communication and share resources among local public health departments.

13. Melanoma of Skin By GenderMales: 2004-2008

14. Melanoma of Skin By GenderFemales: 2004-2008

15. Targeted Risk Groups • Beach goers • Boaters • Fishing industry • Youth at camps • Outdoor sports • Baseball • Softball • Soccer, LAX, field hockey • Golfers • Agricultural workers/CSA • Tanning salon users • Mostly white • Female • 15 to 45 years old • “Prom goers”

16. Green light! Red light! • Melanoma stats • Conducted research • Science says “ban the tan” • 12/18 communities had tanning salons • 40+ tanning salons • Collaborating with industry • Survey-100% • Not permitting/not inspecting • Conflicting views • Lack of tools • Inadequate training • Slow down-generate consensus, support, and buy-in

17. Output: Awareness Campaigns • Launched “Healthy Skin is In” and “Protect the Skin You’re in” • Designed logo and taglines • Developed website www.sunsafety411.org • Full-color tri-fold brochure, 6-foot banner, and SPF promotional packets • Developed 30 and 60 second PSAs on North Shore Radio 104.9 FM targeting: • Youth/Families • Men (Recreational) • Indoor tanners

18. Tri-Fold Sun Safety Brochure

19. Output: Educational Trainings • Conducted sun safety trainings and provided SPF product for recreational staff, coaches, and teachers • Collaborated with BU School of Public Health & New England Alliance for Public Health (Local Public Health Institute) in the development of an on-line training module for tanning operators and inspectors • Continue to work with MDPH Bureau of Environmental Health to design and provide “Indoor UV Training” for health inspectors-February 2013 and MHOA Educational Meeting-June 2013.

20. Output: Regional & Consistent Tools

21. Challenges and Lessons Learned • Operational structure is effective and replicable • 18 diverse communities • Varied staffing patterns • Differing resources • Shared goals & develop trust • Time, process, buy-in • Changes in FDA regulations regarding SPF & labeling • Extensive work plan • Municipality purchasing structure & policies • Inadequate training • Importance of regional efforts to develop cohesive planning and inspectional programs, and to identify areas for state collaboration

22. Understand Factors Contributing to Skin Cancer Who is at risk? Good News/Bad News Types of skin cancer Identification of skin cancer: ABCDE Sun AWARE and Prevention Learning Objective #2

23. Skin Cancer: Did you know? • Skin cancer rates are soaring • Most common form of all cancers • Most preventable cancer • 1 in 5 Americans will develop skin cancer at some point in his/her life • 90% of all skin cancers is associated with ultraviolet radiation (UV) • Everyone is at risk for skin cancer regardless of skin type or color (ethnicity)

24. Facts About Skin Cancer • Pre-cancerous Skin Lesions • Actinic keratoses • Basal Cell Carcinoma (BCC) • Most common type of skin cancer • Estimated 2.8 million are diagnosed/yr • Squamous Cell Carcinoma (SCC) • Can be serious if not caught early • 700,000 cases of SCC • Melanoma • Most serious form of skin cancer • More than 75,000 were diagnosed and 8,650 died in 2009 (ACS)

25. Rising Rates of Melanoma • Most common form of cancer for young adults 25-29 years • One person dies of melanoma every hour (57 minutes) • 1 in 50 men/women will be diagnosed with melanoma during their lifetime • From 1970 to 2009, incidence increased by 800% among young women and 400% among young men

26. Good News: Skin Cancer is Preventable • Skin cancer is the most preventable type of cancer • Prevent childhood sunburns • Practice year-round Sun Safety: • Use of Broad-Spectrum SPF 15-50, UPF clothing, hats, sunglasses • Increase access to shade • Reduce UV exposure • Avoid tanning/indoor UV exposure • Use UV index and Fitzpatrick Skin Type Scale

27. Fitzpatrick Skin Type Scale

28. Protect Your Skin: Screening • Skin cancer is almost completely curable when treated early • Screening is Key • Examine your skin regularly • Have your skin checked annually by a health care professional • Monitor your skin and see physician if your moles or freckles have any of the ABCDE signs

29. “ABCDE” Signs & Symptoms

30. Sun Safety: Use SunAWARE Tips Avoid over exposure Wear sun protective clothing Apply broad-spectrum SPF Routinely examine skin Educate others A W A R E

31. Define UV radiation and the effects of UV exposure UVA, UVB, and UVC Understanding role of UV in tanning Using UV Index as protective measure Tanning Physiology Behavioral Tanning Issues Tanning Psychology Learning Objective #3

32. Understanding UV Spectrum

33. Spectrum: UVA, UVB & UVC • Short wavelength, high energy (40-400 nm, between X-rays and visible light), non-ionizing radiation • UVA (320-400 nm) responsible for tanning by stimulating melanocytes and can penetrate through clouds & glass • UVB (280-320 nm) causes sunburn, UVB needed for synthesis of vitamin D • UVC (280-100 nm) blocked by ozone, used in germicidal lamps • Both UVA & UVB damage skin, DNA, and increase risk for skin cancer through photochemical damage

34. Tanning Physiology • Melanocytes and skin layers

35. Skin Cells Understanding Melanocyte to Melanoma 3-Minute Video

36. Tanning Physiology • Electromagnetic spectrum and effects

37. UV Index from National Weather Service/EPA

38. Adverse Effects of UV • Acute and long-term effects of exposure to UV include: • Erythema (sunburn) • Cataracts and corneal burns, photokeratitis, photoconjunctivitis • Skin cancer • Suppression of immune system • Toughening of skin, wrinkling, loss of collagen • Damage to dermal blood vessels • Chemical agents and drugs may exacerbate UV effects (e.g. antibiotics)

39. Vulnerable Populations • All populations are vulnerable to the effects of UV • Of concern are: • Immunosuppressed • Young people under 35 years • Misperceptions of “base tan” or darker skin tones • Access to health care screening and treatment

40. Shedding Light on UV Radiation • World Health Organization (WHO) listed UV, emitted from tanning salons, as a “group 1” carcinogen, and recommends that no one use a tanning bed for cosmetic purposes (2009). • US Department of Health and Human Services also declared UV a “human carcinogen” placing tanning beds in the same cancer-causing category as tobacco.

41. Gain a deeper understanding of the tanning industry and public health implications: Describe risks of tanning devices and its link to skin cancer Health basis for regulatory control Behavioral Factors Tanning promotion & messaging Learning Objective #4

42. Tanning Facilities linked to Skin Cancer: Research Findings • Exposure to indoor tanning enhances risk for skin cancer, including melanoma by 75% (COMARE, IARC). • Indoor tanners have a 69% increased risk of basal cell carcinoma • 1 session increases chance of developing melanoma by 20% • 4 sessions/year increases risk of BCC and SCC by 15% • Risk increases with exposure to indoor tanning before age 35 and is highest based on exposure before age 18 (WHO, FDA, AADA, CDC) • Cells that are changing or in transition are most vulnerable to effects of radiation.

43. Health Basis for Regulatory Control of Tanning Facilities • WHO/IARC concludes from the 19 studies conducted over 25 years there is the evidence of squamous cell carcinoma and melanoma due to indoor tanning. Risk of melanoma increases by 75% among when use starts before age 35 • Melanoma and all skin cancers are steadily increasing • Melanoma incidence rates have climbed for past 30 years • Estimated 76,250 new cases of melanoma will occur in the U.S. this year-a rise of 6,020 cases from 2011 (ACS, 2012)

44. Indoor UV Tanning Ray is Stronger • UV rays from tanning beds are 12 X stronger than the sun • UVA is the “tanning” ray which tanning beds primarily emit (95% of total) • UVB is the chief cause of skin reddening and sunburn • UVA and UVB penetrate deep into skin and damage DNA, contributing to development of all skin cancers • UVA and UVB damages skin cells • squamous cells • keratinocytes in the basal cell layer of the epidermis causing basal cell carcinoma • melanocytes causing melanoma

45. Indoor Tanning and Teens • The skin of teens is more vulnerable because their cells are dividing and changing more rapidly than those of adults. • 37% of white female adolescents and over 11% of white male adolescents between 13 and 19 years old in the US have used tanning booths within last year. • Fairer skin, eyes, at highest risk for skin damage. • Conclusion: Highest risk group (young, Caucasian) is also highest user group!

46. Tanning Psychology • 2005 American Academy of Dermatology Survey (AAD) • 95% of respondents understood that getting a tan is dangerous • 65% said they think they look better with a tan. • 1 out of 3 teenagers say they tan because it “looks healthy” • An AAD survey found that more than 80% of people aged 25 and younger said they looked better with a tan.

47. Tanning & Addiction • Frequent tanners show signs of both physical and psychological dependence • UV light has show to increase release of opioid-like endorphins • Frequent tanners report benefits of mood enhancement, relaxation and difficulty quitting use • A 2006 study showed 95% of frequent tanners could distinguish between UV and non-UV light emitting tanning beds (brain activity supported this) compared with non-frequent users who could not discern

48. Indoor Tanning Statistics • Approximately 30 million Americans go to tanning salons annually • 70% of all users are Caucasian women, ages16-49 • Use rates are increasing among males and Latinos • 2.3 million US teens visited a tanning salon in last year • 1 in 4 of ALL US teen girls have used indoor UV tanning devices (lifetime)

49. Tanning Industry • Indoor tanning is a $5 billion-a-year industry • 25,000+ tanning salons in U.S. • More prevalent than McDonald’s or Starbucks • 600 “stand alone” tanning salons in MA • Sun Safety region: 40+ tanning facilities in 18 communities • Increasing number of tanning services in gyms and salons

50. Promotional Messages • Get your vitamin D here “cancer prevention” • Beauty “look better” • “Sun-Kissed” • “Healthy Glow”