FREQUENT TANNING PARLOR

STUDY UV Tanning Advertisements in High School Newspapers Scott Freeman, MD; Shayla Francis, MD; Kristy Lundahl, MBA, MS; Terri Bowland, DO; Robert P. Dellavalle, MD, PhD, MSPH Objective: To examine the increasing use of UV tanning parlors by adolescents, despite the World Health Organization recommendation that no one under the age of 18 years use UV tanning devices. Design: We examined tanning advertisements in a sample of public high school newspapers published between 2001 and 2005 in 3 Colorado counties encompassing the Denver metropolitan area. Results: Tanning advertisements appeared in newspapers from 11 (48%) of 23 schools. Newspaper issues (N=131) contained 40 advertisements placed by 18 tanning parlors. Advertisements commonly offered discounts (19 of 40) including unlimited tanning offers (15 of 40). Thirteen advertisements featured non-uv tanning treatments, and 2 advertisements mentioned parental consent or accompaniment for UV tanning. Conclusions: UV radiation, a classified carcinogen, is commonly and specifically marketed to adolescents through high school newspaper advertising. Public health skin cancer prevention policies should include the prohibition of UV tanning advertising to minors. Arch Dermatol. 2006;142:460-462 Author Affiliations: Department of Dermatology, University of Colorado at Denver Health Sciences Center, Aurora (Drs Freeman, Francis, and Bowland and Ms Lundahl); and Denver Veterans Affairs Medical Center, Denver, Colo (Dr Dellavalle). FREQUENT TANNING PARLOR use by female adolescents mirrors the increasing incidence of skin cancer in young women 1 and has prompted the World Health Organization to recommend that persons younger than 18 years should not use indoor UV radiation tanning devices. 2 Although regulations restrict youth-targeted advertising of other carcinogens such as tobacco, no regulations limit youth-targeted advertising of indoor UV tanning. 3 METHODS Public high schools within 3 Colorado counties encompassing the Denver metropolitan area were identified from online listings and telephoned (list of schools available in an online ebox [http://www.archdermatol.com]). School representatives were asked to supply 3 or more newspapers printed in 2001 or later. Submitted newspapers, either mailed in or picked up by investigators at the high school, were used to create a database. Data collection began October 1, 2004, and ended September 15, 2005 (Figure). The following terms were defined: tanning advertisement (any business advertisement located within a newspaper that included the word tanning ) and unlimited tanning (any advertisement offering unlimited tanning, no limit tanning, or packages without maximums on amount of use during a specified period). Advertisements were also examined for other discounts, UV-free or sunless tanning, and requirements for parental consent or age restrictions. Advertisement densities (the number of advertisements published in a given season divided by the number of newspapers published in the same season) were calculated for seasons. Seasons were defined as winter (December, January, and February); spring (March, April, and May); summer ( June, July, and August); and fall (September, October, and November). Additional data recorded in a Microsoft Access (Microsoft Corp, Redmond, Wash) database included advertisement text, size, date, and source newspaper. Data were double-entered by 2 separate individuals and resolved for discrepancies, and descriptive statistics were generated. All collected data were transferred into a Microsoft Access database, and all statistical analyses were conducted using SAS version 9.1 (SAS Institute, Cary, NC) software. RESULTS Twenty-three Denver-area public high schools submitted 131 newspaper issues with commercial advertising (Table). 460

63 High Schools Telephoned 57 Accepted Contact by Telephone (3 Attempts) 3 With Newspapers 34 With Newspapers Accepting Commercial Advertisements 23 High Schools Provided Newspapers With Commercial Advertisements (n = 131 Newspaper Issues) Figure. High school newspaper collection. Newspapers received were published between 2001 and 2005 and were most commonly published in 2004 (available in an online efigure [http://www.archdermatol.com]). Newspapers received were most commonly published in the months of May and September (n=19) and least commonly published in the month of July (n=0). At least 1 issue of newspapers from 11 schools contained UV tanning advertising (Table). Eighteen unique establishments placed the 40 tanning advertisements found. The highest density of advertisements was found in newspapers published during the spring (spring [0.47]advertisements per number of newspapers published vs winter [0.20], summer [0.25], and fall [0.23]), particularly during the month of April (0.58). Up to 3 advertisements were found in a single newspaper, the largest being one-half page (20 26 cm) and the smallest, 8 10 cm (mean, 11 13.5 cm). Tanning salon advertisements commonly promoted unlimited tanning offers (15 of 40) for periods of up to 4 months. Discounts, often requiring student identification or described as prom specials, were mentioned in 19 (48%) of 40 advertisements and included 50%-off promotions and monthly unlimited tanning for as little as $19.99. Thirteen advertisements (33%) featured non-uv tanning treatments. Two advertisements (5%) mentioned parental guidance: parental consent and accompaniment was required for those younger than 16 years at one establishment, and parental consent was required for those younger than 18 years at the other establishment. One advertisement included the restriction that no one 14 years and younger was permitted to tan. COMMENT Table. High School UV Tanning Advertisements Variable Value Date range of all newspaper issues December 2001 June 2005 Unique establishments advertising UV 18 tanning, No. Issues of newspapers with commercial advertisements collected per school Range 3-12 Mean 6.8 Mode 7 Advertisements per issue of newspaper with a UV tanning advertisement Range 1-3 Mean 1.5 Mode 1 Size of advertisements (height width, cm) Range 8 10 to 20 26 Mean 11 14 Mode 10 10 Indoor UV tanning advertisements, No. 40 Advertisement feature, No. (%) Offering unlimited tanning 15 (38) Discounts 19 (48) Require parental guidance 2 (5) Age restriction (age 15 y) 1 (3) UV-free or sunless tanning 13 (33) This study documents abundant UV tanning advertising in public high school newspapers in Denver, a metropolitan area without indoor UV tanning youth access restrictions. 3 The study has several limitations: (1) results were not derived from a complete or a randomly selected sample of newspapers, and (2) the data set is too limited to present time trend analysis for particular advertisement subgroups. Similar to a previous study of indoor tanning advertisements in 24 San Diego, Calif, commercial newspapers, we also found that unlimited tanning packages were common. 4 The escalating cost of treating skin cancers 5 mandates a public health policy response. Both metaanalysis and case-control data exist, linking UV radiation from tanning beds and sunlamps to melanoma 6 and nonmelanoma skin cancers. 7 UV-free tanning options, especially the use of spray-on application systems of dihydroxyacetone-containing tanning solutions, offer teenagers and tanning salons an alternative to UV tanning. Interestingly, a recent study suggests that, like smoking, tanning may be addictive. 8 The banning of youthdirected advertising of other carcinogens, namely tobacco, provides a model for public policy response. The UV radiation emitted from sunlamps and sun beds is classified as a group 2A carcinogenic agent by the International Agency for Research on Cancer. 9 Further advocacy of legislative restrictions on tanning marketing to adolescents should be adopted. Accepted for Publication: December 19, 2005. Correspondence: Robert P. Dellavalle, MD, PhD, MSPH, Denver Veterans Affairs Medical Center, Dermatology Service, 1055 Clermont St, Mail Code No. 165, Denver, CO 80220 (robert.dellavalle@uchsc.edu). Author Contributions: Study concept and design: Dellavalle, Francis, and Freeman. Acquisition of data: Freeman, Lundahl, Francis, and Bowland. Analysis and interpretation of data: Freeman and Dellavalle. Drafting of the manuscript: Freeman, Francis, and Dellavalle. Revision of the manuscript for important intellectual content: Freeman and Dellavalle. Statistical analysis: Freeman and Dellavalle. Study supervision: Dellavalle. Dr Dellavalle, as the principal investigator of this study, had complete ac- 461

cess to the data and takes responsibility for the integrity of the data and the accuracy of the data analysis. Financial Disclosure: None. Funding/Support: This study was supported by the Colorado Department of Health and the Environment, Denver; grant K-07CA92550 from the National Cancer Institute, Bethesda, Md (Dr Dellavalle); and the Department of Dermatology, University of Colorado at Denver and Health Sciences Center. Previous Presentation: This study was presented at the Society of Investigative Dermatology Annual Meeting; May 4-8, 2005; St Louis, Mo. Additional Resources: The online-only ebox and efigure are available at http://www.archdermatol.com. Acknowledgment: We thank Kathryn Johnson, MD, for help with manuscript preparation, David Crockett for assistance with data entry, and Jennifer Myers, MD, for aid with study preparation. We also thank Sara Miller, MPA, and the members of the Colorado Skin Cancer Task Force, Colorado Department of Health and the Environment, for their input. REFERENCES 1. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA. 2005;294: 681-690. 2. Hartl G. The World Health Organization recommends that no person under 18 should use a sun bed. World Health Organization Web site. Available at: http://www.who.int/mediacentre/news/notes/2005/np07/en/. Accessed June 27, 2005. 3. Francis SO, Burkhardt DH, Dellavalle RP. A banner year for new US youth access tanning Regulations. Arch Dermatol. 2005;141:524-525. 4. Kwon HT, Mayer JA, Walker KK, Yu H, Lewis EC, Belch GE. Promotion of frequent tanning sessions by indoor tanning facilities: two studies. J Am Acad Dermatol. 2002;46:700-705. 5. Housman TS, Feldman SR, Williford PM, et al. Skin cancer is among the most costly of all cancers to treat for the Medicare population. J Am Acad Dermatol. 2003;48:425-429. 6. Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev. 2005;14:562-566. 7. Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 2002;94:224-226. 8. Warthan MM, Uchida T, Wagner RF. UV light tanning as a type of substancerelated disorder. Arch Dermatol. 2005;141:963-966. 9. World Health Organization, International Agency for Research on Cancer. Solar and Ultraviolet Radiation: Summary of Data Reported and Evaluation. Vol. 55. Lyon, France: International Agency for Research on Cancer; 1992. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. ARCHIVES Web Quiz Winner C ongratulations to the winner of our January quiz, Vincent Descamps, MD, PhD, Department of Dermatology, Bichat Claude Bernard Hospital, AP-HP, Paris, France. The correct answer to our January challenge was filiform hyperkeratosis. For a complete discussion of this case, see the Off-Center Fold section in the February ARCHIVES (Blanes M, Carnicer F, Botella R, Pastor N, Peiró FM. Filiform horny projections on the palms of a 69- year-old man. Arch Dermatol. 2006;142:235-240). Be sure to visit the Archives of Dermatology Web site (http://www.archdermatol.com) to try your hand at the interactive quiz. We invite visitors to make a diagnosis based on selected information from a case report or other feature scheduled to be published in the following month s print edition of the ARCHIVES. The first visitor to e-mail our Web editors with the correct answer will be recognized in the print journal and on our Web site and will also receive a free copy of The Art of JAMA II. 462

WEB-ONLY CONTENT Denver-Area Public High Schools, Colorado Arapahoe County Cherry Creek High School Heritage High School Arapahoe High School Aurora Central High School Gateway High School Rangeview High School Englewood High School Grandview High School Hartenbach High School Hinkley High School Joliet High School Overland High School Smoky Hill High School William Smith High School Byers Junior-Senior High School Eaglecrest High School Deer Trail Junior-Senior High School Sheridan High School Colorado s Finest Alternative High School Littleton High School Ridge View Academy Charter School Jefferson County Wheat Ridge High School Standley Lake High School Conifer High School Ralston Valley High School Chatfield Senior High School Bear Creek High School Jefferson High School Dakota Ridge High School Arvada High School Lakewood High School Alameda High School Arvada West High School Columbine High School D Evelyn High School Evergreen High School Golden High School Green Mountain School Jefferson County Open High School McLain High School Pamona High School Sobesky Academy High School Denver County South High School Thomas Jefferson High School JFK High School West High School East High School Denver School of the Arts Abraham Lincoln High School Arts and Cultural Studies Academy at Manual Colorado High School Contemporary Learning Academy High School Emerson Street School Emily Griffith Opportunity School Expeditionary Learning School Florence Crittenton High School Fred N. Thomas Career Education Center George Washington High School Leadership Academy at Manual Millennium Quest Science Academy at Manual Montbello High School North High School PS 1 Charter High School Web Sites Used Jefferson County public high schools: http://jeffcoweb.jeffco.k12.co.us/school/ Arapahoe County public high schools: http://www.publicschoolreview.com/county _public_schools/stateid/co/county/8005 Denver County public high schools: http://www.publicschoolreview.com/county _public_schools/stateid/co/county/8031 High school telephone numbers: http://www.dexonline.com E1

WEB-ONLY CONTENT Cumulative Cumulative Frequency Frequency Percentage Percentage 2001 1 1 0.76 0.76 2002 3 4 2.29 3.05 Year 2003 22 26 16.79 19.85 2004 89 115 67.94 87.79 2005 16 131 12.21 100.00 0 20 40 60 80 100 Frequency efigure. Newspapers collected by year. E1

Yones and Palmer. Drafting of the manuscript: Yones and Palmer. Critical revision of the manuscript for important intellectual content: Yones, Palmer, Garibaldinos, and Hawk. Statistical analysis: Yones and Palmer. Obtained funding: Yones. Administrative, technical, and material support: Yones and Hawk. Study supervision: Hawk. Financial Disclosure: None reported. Acknowledgment: We thank the staff of The Dowling Day Treatment Unit (including Maria Csazar), the staff of the Skin Therapy Research Unit, and Jonathan Barker, MD, Mohammed Ben-Gashir, PhD, Paul Seed, MSc, and Manal Bugossa, Dip. REFERENCES 1. Van Weelden H, Baart de la Faille H, Young E, van der Leun JC. Comparison of narrow-band UV-B phototherapy and PUVA photochemotherapy in the treatment of psoriasis. Acta Derm Venereol. 1990;70:212-215. 2. Tanew A, Radakovic-Fijan S, Schemper M, Honigsmann H. Narrowband UV-B phototherapy vs photochemotherapy in the treatment of chronic plaque-type psoriasis: a paired comparison study. Arch Dermatol. 1999;135:519-524. 3. Dawe RS, Cameron H, Yule S, et al. A randomized controlled trial of narrowband ultraviolet B vs bath-psoralen plus ultraviolet A photochemotherapy for psoriasis. Br J Dermatol. 2003;148:1194-1204. 4. Gordon PM, Diffey BL, Matthews JN, Farr PM. A randomized comparison of narrowband TL-01 phototherapy and PUVA photochemotherapy for psoriasis. J Am Acad Dermatol. 1999;41:728-732. 5. Markham T, Rogers S, Collins P. Narrowband UV-B (TL-01) phototherapy vs oral 8-methoxypsoralen psoralen UV-A for the treatment of chronic plaque psoriasis. Arch Dermatol. 2003;139:325-328. 6. Tahir R, Mujtaba G. Comparative efficacy of psoralen-uva photochemotherapy versus narrow band UVB phototherapy in the treatment of psoriasis. J Coll Physicians Surg Pak. 2004;14:593-595. 7. Fredriksson T, Pettersson U. Severe psoriasis: oral therapy with a new retinoid. Dermatologica. 1978;157:238-244. 8. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol. 1994;19:210-216. 9. British Photodermatology Group. British Photodermatology Group guidelines for PUVA. Br J Dermatol. 1994;130:246-255. 10. George SA, Collins P, Wainwright NJ, et al. Narrow-band UVB psoriasis phototherapy: normal vs. low (half ) dose irradiation regimens [abstract]. Br J Dermatol. 1993;129:66. 11. Hofer A, Fink-Puches R, Kerl H, Wolf P. Comparison of phototherapy with near vs. far erythemogenic doses of narrow-band ultraviolet B in patients with psoriasis. Br J Dermatol. 1998;138:96-100. 12. Man I, Dawe RS, Ferguson J, Ibbotson SH. An intraindividual study of the characteristics of erythema induced by bath and oral methoxsalen photochemotherapy and narrowband ultraviolet B. Photochem Photobiol. 2003;78:55-60. 13. Green C, George S, Lakshmipathi T, Ferguson J. A trial of accelerated PUVA in psoriasis. Clin Exp Dermatol. 1993;18:297-299. 14. Melski JW, Tanenbaum L, Parrish JA, Fitzpatrick TB, Bleich HL. Oral methoxsalen photochemotherapy for the treatment of psoriasis: a cooperative clinical trial. J Invest Dermatol. 1977;68:328-335. 15. Sakuntabhai A, Sharpe GR, Farr PM. Response of psoriasis to twice weekly PUVA. Br J Dermatol. 1993;128:166-171. 16. Cameron H, Dawe RS, Yule S, Murphy J, Ibbotson SH, Ferguson J. A randomized, observer-blinded trial of twice vs. three times weekly narrowband ultraviolet B phototherapy for chronic plaque psoriasis. Br J Dermatol. 2002;147:973-978. 17. Dawe RS, Wainwright NJ, Cameron H, Ferguson J. Narrow-band (TL-01) ultraviolet B phototherapy for chronic plaque psoriasis: three times or five times weekly treatment? Br J Dermatol. 1998;138:833-839. 18. Dawe RS, Cameron H, Yule S, Man I, Ibbotson SH, Ferguson J. UV-B phototherapy clears psoriasis through local effects. Arch Dermatol. 2002;138:1071-1076. 19. Morison WL. PUVA therapy. In: Phototherapy and Photochemotherapy of Skin Disease. 2nd ed. New York, NY: Raven Press; 1991:93-131. 20. Jayaprakasam A, Darvay A, Osborne G, McGibbon D. Comparison of assessments of severity and quality of life in cutaneous disease. Clin Exp Dermatol. 2002; 27:306-308. 21. Diffey BL. Factors affecting the choice of a ceiling on the number of exposures with TL01 ultraviolet B phototherapy. Br J Dermatol. 2003;149:428-430. 22. Lim JL, Stern RS. High levels of ultraviolet B exposure increase the risk of nonmelanoma skin cancer in psoralen and ultraviolet A treated patients. J Invest Dermatol. 2005;124:505-513. Correction Error in Figure. In the Study by Freeman et al titled UV Tanning Advertisements in High School Newspapers, published in the April issue of the ARCHIVES (2006;142:460-462), an editorial error was introduced by the journal in the Figure on page 461. In the Figure, the third box down should have read 37 With Newspapers instead of 3 With Newspapers. The corrected Figure is reproduced herein. 63 High Schools Telephoned 57 Accepted Contact by Telephone (3 Attempts) 37 With Newspapers 34 With Newspapers Accepting Commercial Advertisements 23 High Schools Provided Newspapers With Commercial Advertisements (n = 131 Newspaper Issues) Figure. High school newspaper collection. (REPRINTED) ARCH DERMATOL/ VOL 142, JULY 2006 842