Leading international health organisations are concerned about high use of artificial tanning services and the associated risk of skin cancer. Similar concerns exist about the growing Australian solarium industry.
Pre-teens appear to be ignoring sun safety messages in their desire to tan and use solaria.
A significantly elevated risk of melanoma exists among people exposed to artificial ultraviolet radiation; the risk is higher for those younger than 35 years at first solarium use. For all users, the risk of squamous cell carcinoma is more than doubled compared with non-users.
We estimated the numbers of new melanoma cases and melanoma-related deaths attributable to solarium use by younger people in the five most populous Australian states and indirectly quantified potential costs to the health system that could be saved by effective regulation of the solarium industry.
Annually, 281 new melanoma cases, 43 melanoma-related deaths and 2572 new cases of squamous cell carcinoma were estimated to be attributable to solarium use.
The annual cost to the health system — predominantly Medicare Australia — for these avoidable skin cancer cases and deaths is about $3 million.
By successfully enforcing solarium regulations that ban use by people younger than 18 years or with fair skin, favourable health and cost benefits could be expected.
In September 2007, the highly publicised death of Clare Oliver,1 a young Victorian woman who had used tanning solaria, drew attention to the solarium industry in Australia and the potential increased risk of skin cancer due to exposure to artificial ultraviolet (UV) radiation. In the wake of her death, the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) commissioned a report on the health effects of solarium use and the potential cost-effectiveness from the government’s viewpoint of fortifying the existing voluntary Standard.2 State governments in Victoria, South Australia and Western Australia recently implemented laws that mandate training for solarium operators and restrict access for people younger than 18 years or with fair skin, and Queensland and New South Wales governments have announced similar plans.
State cancer councils and other health agencies in Australia, in line with international health organisations such as the World Health Organization, have called for tighter controls of the solarium industry. Here, we discuss the case for government regulation of solaria in Australia and present our model of the number of new cases of melanoma, melanoma-related deaths and new cases of squamous cell carcinoma (SCC) that are attributable to solarium use.
In 2004, the Australian Government Radiation Health Committee issued a position statement3 that encouraged compliance with the Australian/New Zealand Standard on solaria for cosmetic purposes (AS/NZS 2635:2002) — a voluntary code of practice designed to provide solarium operators with procedures to minimise the health risks associated with indoor tanning.4 These include:
banning solarium use by people younger than 15 years or with fair skin, but allowing people between 15 and 18 years to use solaria with parental consent;
allowing sunbed emission up to UV Index 60 (five times typical summer sun);
training on standardised skin-type assessment for solarium operators;
supervision of solaria by trained operators at all times; and
use of client consent forms before tanning.
However, five Australian studies have revealed that solarium operators comply poorly with the Standard, with respect to prohibiting use by fair-skinned individuals, obtaining informed consent before use, adhering to minimum age limits and displaying warning signs.5-9 Also, conformity to the technical elements of the Standard (ie, sunlamp emission intensity, replacement of ageing lamps and operator training) is unknown.
Furthermore, a contentious point in the Standard is that it allows radiation intensity levels up to five times those possible from solar radiation. In fact, tests by ARPANSA of 15 sunbeds manufactured in Europe or the United States, used in Melbourne and Sydney, showed that levels of UV radiation intensity were equivalent to a UV Index of 15–38 — three times stronger than the midday summer sun in Brisbane. Although UVB emissions accounted for 0.4%–2.9% of all emissions, they accounted for 70%–80% of the erythemal effect. All solaria had higher total UVB emissions than the midday summer sun in Brisbane, and 30% had higher UVB emissions in the under-310 nm wavelength range.
Conventionally, governments intervene in an industry where there is market failure. The promotion of solaria for non-cosmetic health benefits (Box 1), failure of the industry to self-regulate through the agreed Standard, and lack of risk awareness among solarium users all suggest that government regulation is necessary.
Recent audits show that the numbers of solarium-related businesses have increased fourfold in most Australian cities and sixfold in Melbourne since 1992.14 Compared with findings outside Australia, the prevalence and frequency of the general population’s use of solaria is low: about 0.9%–3.0% of the Australian population (approximately 400 000 people) used solaria in 2006. However, use among adolescents and women is higher, with one study showing that 12% of NSW school children had used solaria.15 Three surveys indicate 22%–39% of solarium users are regular users,16,17 and one study found 35% used a solarium one to four times a fortnight.17 Alarmingly, and despite decades of sun-protection campaigns, this survey also showed that Australian adolescents remain bold and experimental, as a substantial proportion of pre-teens intended to use a solarium.15 Childhood exposure to UV radiation is a major determinant of melanoma risk in later life, indicating that childhood may be a critical period in which the skin is vulnerable to irreparable UV-induced damage.18 Exposure at ages 10–24 years also appears important in promoting melanoma development.19
Evidence of the link between artificial UV radiation exposure and melanoma has been accumulating for years. Reviews published in 1994 and 2006 both concluded that solarium users have a higher risk of developing melanoma than non-users.12,13 The risk was 75% higher for those younger than 35 years at first solarium use (the most common users), and the corresponding risk of SCC of the skin was more than doubled.13 In comparison, the overall risk of melanoma for all users was increased by 15%.13 However, most studies have been based in North America or Europe, so their relevance to Australia is unclear.
Fair skin (Type I on the Fitzpatrick scale) is associated with a doubling of skin cancer risk, compared with darker skin.20 Hence banning individuals with Type I skin should be an integral part of any regulatory program. A high percentage of Australians are fair-skinned,21 and many exhibit other key phenotypic risk factors for skin cancer, such as blue/green eyes, light-coloured hair and moderate to high prevalence of melanocytic naevi. Additionally, Australia has a high ambient solar UV radiation level for most of the year,22 which potentiates the risk of skin cancer. If an increasing proportion of young people begin using high-intensity sunbeds, the skin cancer burden in Australia will escalate further. However, in the absence of a well designed Australian study, the precise effects of solarium use on skin cancer rates in Australia23 remain speculative.
In 2003, Diffey estimated the annual number of melanoma-related deaths attributable to artificial UV radiation in the United Kingdom to be approximately 100 (95% CI, 50–200).19 We replicated Diffey’s model using Australian data from the five most populous states. Our focus was on tanning behaviour of individuals younger than 40 years. We incorporated the most recent Australian data on outdoor UV radiation exposure,24 melanoma incidence23 and mortality,25 as well as results of recent tests by ARPANSA of UV radiation emission from sunbeds currently used in Australia.
Results of our model are shown in Box 2. We estimated that the annual number of new melanomas attributable to solarium use is highest in Queensland (121), followed by NSW (75) and Victoria (51), and that 43 melanoma-related deaths attributable to solarium use may occur per year across the five states. In addition, 2572 new cases of SCC are potentially attributable to solarium use.
The potential cost savings to the health system (mainly Medicare Australia) of avoiding primary care treatment of these new cases of melanoma is estimated to be $500 000 per year, and an estimated $2.5 million could be saved on treatment of new cases of SCCs (for cost-estimation methods, see reference 2). This includes hospitalisation costs for treatment of 43 patients with advanced-stage cancer only (corresponding to the estimated melanoma-related deaths), as new melanoma and SCC cases are typically treated in primary care settings,31 where Medicare meets the costs. Skin cancer is the most expensive cancer to treat in Australia, and costs are continuing to rise rapidly.32 Recent Medicare statistics show that the costs per 100 000 people for standard SCC and basal cell carcinoma excisions rose up to 34% between 2000 and 2006.33 However, the full annual costs for skin cancers — including doctors’ visits, excision, other treatments, pathology and follow-up — are unknown.
Our model has several limitations: it does not account for the latent period between UV radiation exposure and development of melanoma (it assumes incidence and mortality remain constant); it does not explicitly deal with fair-skinned individuals; and, although the action spectrum for human melanoma induction is unknown, it assumes that the spectra from sunbeds and sunlight are equally carcinogenic. However, the model does provide benchmark information by estimating the harmful impact of UV radiation exposure associated with solarium use, and the human and economic costs that could be avoided by effective solarium regulation.
Unlike other risk factors for chronic diseases that are not modifiable (eg, ageing and genetic predisposition), personal exposure to UV radiation can be controlled through structural, behavioural, educational and health promotion initiatives. Many campaigns over the past three decades have promoted sun-protection behaviour at a population level. Workplace standards specify Ultraviolet Protection Factor (UPF) rating of clothing and sunscreens, “SunSmart” policies exist in schools and early childhood centres, and warnings about the solar UV Index are publicised through the mass media. It is possible that the benefits of these dedicated efforts to protect Australians from developing skin cancer will be partly negated if the solarium industry is not regulated. Thus, there is a strong case for national regulation in Australia, notwithstanding the recognition that intentional sunbathing outdoors is a far greater behavioural problem than indoor tanning (Box 2). Investment in broad sun-protection policies at a population level remains critical. The human and economic burden of skin cancer in Australia is already formidable and will continue to grow in the absence of concerted government, industry and individual efforts to avoid excessive exposure to UV radiation — both solar and artificial.
1 Current debate on the health effects of solarium use*
2 Estimation of annual numbers of new cases of melanoma and squamous cell carcinoma, and melanoma-related deaths attributable to solarium use by younger people in the five most populous Australian states*
UVR = ultraviolet radiation. SED = standard erythemal dose (a measure of the erythemally effective UVR — the effect of UVR on human skin; 2 SED is typically required to produce sunburn of fair skin). SCC = squamous cell carcinoma.
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