Medical Malpractice

There is growing concern about the link between cosmetic sun bed use and the rising incidence of skin cancer in Scotland. This issue was highlighted at the Scotland Against Cancer conference last year at which a case was made for thorough regulation of sun bed operators. It was felt that tighter controls could have a positive impact on skin cancer prevention efforts.

Individuals and organisations with an interest in skin cancer prevention have continued to express concern about rising sun bed use and the effect this may have on levels of skin cancer which is the fastest rising cancer in Scotland, and a particular problem in the West of Scotland. The risk of skin cancer is related to lifetime exposure to ultraviolet light and intense exposure to such light is the most dangerous to the skin. For example, too much time spent in the sun on holidays abroad or excessive time spent in the sun on the occasional hot day in Scotland, constitutes this type of exposure.

Sun bed use also provides a form of intense exposure to ultraviolet light. Just one session a month will double the average individual's annual dose of ultraviolet radiation. Sun bed use is on the rise in Scotland and there is now a significant body of evidence to suggest that the sunbed industry suffers from a lack of regulation. Cases of malpractice by operators have been documented in a survey by the Royal Environmental Health Institute of Scotland (REHIS). In particular there is evidence that children, who are especially sensitive to ultraviolet light, are now regularly using sunbeds. Just one day of burning as a child increases the risk of getting skin cancer as an adult.

Tanning in General

Tanning is your body's natural protection against sunburn; it's what your body is designed to do. Developing a tan is your body's natural way of protecting against the dangers of sunburn and further exposure.

Whether you tan outdoors under the sun or indoors in a tanning facility, the tanning process is the same. This natural process takes place when your skin is exposed to ultraviolet light. Light is composed of energy waves that travel from the sun to the Earth. Each energy wave can be identified by its length in nanometres, (nm), which is one-billionth of a meter. Light can be broken into three general categories: infrared, visible and invisible. Ultraviolet light is in the invisible light spectrum. There are three kinds of ultraviolet light: UVA, UVB and UVC. Tanning itself takes place in the skin's outermost layer, the epidermis. There are three major types of skin cells in your epidermis: basal cells, keratinocytes and melanocytes. All play different roles in the tanning process. Everyone has roughly the same number of melanocytes in their bodies--about 5 million. Your heredity determines how much pigment your melanocytes can produce. Melanocytes release extra melanosomes whenever ultraviolet light waves touch them. This produces a tan in your skin.

Skin Types

I. - Always burns; never tans, pale white skin; "Celtic"

II. - Burns easily; tans minimally; White skin

III. - Burns moderately; tans gradually to light brown average; Caucasian skin

IV. - Burns minimally, always tans well to moderately brown; Olive skin

V. - Rarely burns; tans profusely to dark; Brown skin

VI. - Never burns; deeply pigmented; Black skin

Effects of UV

There is a body of scientific research demonstrating that the production of the activated form of vitamin D is one of the most effective ways the body controls abnormal cell growth. Moderate exposure to sunlight is only way for the body to manufacture the vitamin D necessary for producing activated vitamin D.A 1997 report by the National Academy of Sciences Institute of Medicine recommends 200 IU/day of vitamin D for women aged 50 years or younger, 400 IU/day for those aged 51-70 and 600 IU/day for those older than 70. Moderate exposure to sunlight helps the body manufacture vitamin D and eating salmon or mackerel and drinking fortified milk or juices is a step in the right direction. The amount of vitamin D formed in a given period of exposure depends on the colour of your skin--that is, how rich your skin is in melanin. Melanin absorbs UV radiation. Therefore it diminishes the production of vitamin D. The darker a person's skin, the longer he or she has to be in the sun or exposed to UVB radiation to form a significant amount of vitamin D.
Like melanin, sunscreen also absorbs UV radiation and therefore greatly diminishes the skin's vitamin D production. For example, sunscreen with a PDF of 8 diminishes a person's ability to produce vitamin D by 95%. In addition, winter sunlight in the northern latitudes does not have enough UVB radiation to produce vitamin D in the skin leading to diminished vitamin D levels in winter.
Moderate exposure is the most responsible way to maximize the potential benefits of sun or UV exposure while minimizing the potential risks associated with either too much or too little sunlight. Avoiding sunburns is critical to moderation. Experiencing painful sunburns before the age of 20--not lifetime exposure to the sun--is the factor associated with an increased risk of malignant melanoma, the most serious type of skin cancer.

History and Facts of Indoor Tanning

Europeans started tanning indoors with sunlamps that emitted ultraviolet (UV) light as a therapeutic exercise to harness the positive psychological and physiological effects of exposure to UV light. This practice became widespread in Europe, particularly in the sun-deprived northern countries by the 1970s--several years before the first indoor tanning facility was established in the UK. Although indoor tanning is considered a cosmetic exercise the roots are therapeutic and many people do in fact visit tanning facilities for that purpose.

The indoor tanning industry has grown substantially in 25 years. Today it is a strong part of the small business community. And each year about 10 percent of the public visits an indoor tanning facility. This business is estimated to be worth £3 billion worldwide.

The indoor tanning industry's position is summed up in this declaration:

"Moderate tanning, for individuals who can develop a tan, is the smartest way to maximize the potential benefits of sun exposure while minimizing the potential risks associated with either too much or too little sunlight."

The indoor tanning salon industry claims to be part of the solution in the ongoing battle against sunburn by teaching people how to identify a proper and practical life-long skin care regimen. No legislation covers indoor tanning just the following government guidance:

"Like the sun, sun-beds give out UV rays that can increase the risk of skin cancer. The more you use sunbeds, the greater the risk is likely to be and when the tan fades, the skin damage remains. If you're under 16 you should never use a sunbed, as young skin is more delicate and prone to damage than older skin. Even if you are over 16 you should be very careful if you choose to use one. You should also really avoid sunbeds altogether if you:

a. - have fair or freckly skin

b. - burn easily

c. - have a lot of moles

d. - have a family history of skin cancer

e. - use medication that increases your sensitivity to UV.

If you do decide to use one, limit yourself to two sessions a week, over a period of 30 weeks, every year. But remember that if you don't tan in the sun, you won't tan any more easily on a sunbeds."

Skin Cancer

Skin cancer has a 20- to 30-year latency period. The rates of skin cancer we are seeing today are most likely the result of bad habits from the 1960s, 1970s and 1980s that were based on ignorance and misinformation about sun tanning. In those days, many people still considered sunburns an inconvenient right of spring, a precursor to developing a summer tan. People believed that sunburns would "fade" into tans, and so tanners hit the beaches with baby oil and reflectors. Severe burns were commonplace. Today we know how reckless and uninformed that approach was. What's more, the photobiology research community has determined that most skin cancers are related to a strong pattern of intermittent exposure to ultraviolet light in people who are genetically predisposed to skin cancer. These skin cancers are not simply the result of cumulative exposure. Once again, this suggests that heredity and a pattern of repeated sun burning are the primary factors associated with skin cancer.

Melanoma is a cancer of the pigment-producing cells (melanocytes). An increased risk of melanoma has been associated with people who have moles or repeated sunburn experiences as a child or young adult. Most melanomas occur on non-sun-exposed parts of the body. For example, melanoma is infrequently found on the face. Although melanoma accounts for only 5% of all newly diagnosed skin cancer cases each year, it is responsible for the majority of skin cancer deaths. Melanoma is the only form of skin cancer that is aggressive with any regularity.

Heredity, fair skin, an abnormally high number of moles on one's body (above 40) and a history of repeated childhood sunburns have all been implicated as potential risk factors for this disease. As a nation high in Celtic heredity Scotland needs to consider these facts.

Scotland's Skin Cancer Epidemic

Scotland may be experiencing a skin cancer epidemic with the incidence of skin cancer tripling in the last thirty years. There were over 7,000 cases of skin cancer diagnosed in 2001, up from 2,200 in 1975 and higher rates of melanoma incidence have been reported in Scotland than in the rest of the UK.

In the age group 20-39 years, malignant melanoma is the second most common cancer in the UK. This is an unusually young age distribution for an adult cancer and emphasises the importance of its prevention and early treatment to avert the potential loss of many years of life.
On average, about 20 years of life are lost for each melanoma death in the UK.

The NHS and a number of cancer charities have most clearly linked the steep rise in incidence to changing cultural perceptions of a tan as desirable and the steep rise in the number of people taking holidays in the sun.

Tanning grew significantly in popularity through the 1960s, 1970s and 1980s and as skin cancer may take 20 or more years to develop; the high rates of skin cancer can be expected to continue for many years to come.

Mortality from skin cancer, particularly melanoma, it's most aggressive form, has not fallen despite major public health initiatives to raise awareness of sun protection and skin cancer. Attempts are being made by health promotion agencies to tackle this growing problem through encouraging people to change their behaviour on holiday and convincing Scots to take care on sunny days at home.

Another source of ultraviolet light is that derived from sunbed use and medical evidence on the risk of sunbeds to health is increasing. Sunbeds have been linked to a variety of negative health effects, including eye damage, photodermatosis, photosensitivity, premature skin ageing and skin cancer.

Ultraviolet rays from sunbeds have been classified as Group 2A carcinogens by the International Association for Research into Cancer (IARC) that is, "probably causing cancer in humans." Recent analyses from studies in different countries over the last ten years have shown that the use of sunbeds increased the risk of cancer and the risk appears to be higher if use begins early in life.
Furthermore, in the UK a significant study from the British Medical Association found that sunbed users were 2.5 times more likely to develop skin cancer. The risks appear to be higher in the young.

A model has been developed to estimate human ultraviolet exposure to both sunlight and sunbeds, and this information was used to predict the contribution of sunbeds to melanoma mortality in the UK. The results of this study indicate that sunbeds cause 100 deaths from melanomas each year in the UK

The World Health Organisation (WHO) recommended in 2005 that no one under 18 should use a sunbed and that there is a need for guidelines or legislation to reduce the risks associated with sunbed use. WHO argues that growth in the use of sunbeds, combined with the desire and fashion to have a tan, are considered to be the prime reasons behind the fast growth in skin cancers in developed countries. The highest rates are found predominantly in those countries where people are fairest-skinned and where the sun tanning culture is strongest: Australia, New Zealand, North America and northern Europe. The people of Scotland are particularly fair-skinned and therefore at relatively high risk of developing skin cancer.

Risk Associated with Sunbeds Use

Despite common claims, radiation from sunbeds is no safer than exposure to the sun itself. The emission from many sunbeds is greater than that from the midday sun in the Mediterranean. The UVA portion of the emission spectrum can be 10-15 times higher than that of the midday sun.
A 1986 survey found that people believed that sunbeds cause less damage to skin than outdoor tanning. This is partly because of the marketing of sunbeds as a way of getting a 'safer', 'controlled' tan. Positive health claims are still being used to market cosmetic sunbeds.

In 2005 the action of ultraviolet light on skin to synthesise Vitamin D in the body was used in an advertisement funded by The Sunbed Association to promote the use of sunbeds as healthy. When a consumer complained about the inference, the Advertising Standards Authority upheld the complaint, in recognition of the fact that health professionals do not recommend sunbeds as the main source of Vitamin D, because of the risk associated with skin damage and cancer.
This was also the conclusion of the recent American Academy of Dermatology conference in May 2005. This conference reviewed evidence and recommended that Vitamin D supplements are a safer, cheaper and better alternative to raise Vitamin D levels than ultraviolet light, especially for the frail elderly and possibly for dark-skinned people with low sun exposure. Because of the documented causal relationship between skin cancer and sunbeds, many international and UK health organizations have publicly recommended that sunbeds should not be used, or their use should be limited and regulated to protect public health.

Lack of Regulation

There exists no relevant legislation other than the general Health and Safety guidance, mentioned earlier, to control the use of sunbeds.

The HSE has issued guidelines and cosmetic sunbed premises and machines are subject to the requirements of health and safety legislation in Scotland. Control of exposure is governed by the general provisions of the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulation 1999.

To comply with this legislation, duty holders are required to assess the health and safety risks caused by their work activities which will include the risks to employees and customers from exposure to ultraviolet radiation and put in place measures to control these risks as far as is reasonably practicable.

Specific guidance has been issued by the HSE on Controlling the Risks from the Use of Ultraviolet Tanning Equipment and can be found at:

http://www.hse.gov.uk/pubns/indg209.pdf

Some businesses operate under a voluntary code of conduct agreed by the Sunbed Association. The Sunbed Association claims 20-25% of cosmetic sunbed premises are in membership. Consequently, with those numbers, voluntary arrangements can only have limited effect.

Although the Sunbed Association provides training schedules, there appears to be no requirement for training associated with the use of non-therapeutic UV radiation. The responsibility is on the provider to supply appropriate information that will allow potential clients to make an informed decision about whether or not sunbeds are suitable for their use. International legislation is diverse but it is significant that the need for regulation is recognized in France, Belgium, Sweden, Canada and the USA. European standards exist to regulate ultraviolet lamp emission strength and sunbed products.

The Case for Sunbed Salon Licensing

It is only within the last decade that public health authorities in Scotland have begun to highlight the health risks associated with sunbed use and in particular, the increased risk of developing skin cancer. In the past, many local authorities provided tanning facilities within their own leisure centres. The association of sunbeds with leisure facilities reinforced the perception that a tan is a sign of good health. Fortunately, over the last decade most sunbeds have been removed from local authority premises. In the main, this has been done because local authorities perceive this to be an action they can take to discourage the use of sunbeds for cosmetic tanning purposes, and to highlight the dangers associated with use.

In addition, the problem of skin cancer has often been viewed as a local community issue, with the subsequent onus on local authorities to take action. However, while the provision of sunbeds in local authority facilities has decreased, the number of commercial sunbed premises has increased.
Furthermore, there are growing concerns that some cosmetic sunbed premises are poorly run and offer little advice on the health risks associated with sunbed use.

A 2003 REHIS survey of 794 cosmetic sunbed premises in all 32 Scottish local authority areas identified a number of un-staffed and unsupervised premises and salons that were failing to check the age of customers or enquire about skin type or medical conditions which may deem sunbed use particularly ill advisable. In addition, the survey highlighted a number of salons that were failing to offer customers adequate eye protection.

Surveys in the UK and North America show that tanning salon operators typically show ignorance of sunbed risks and fail to enforce rules for using sunbeds.

The University of Dundee and Perth and Kinross Council in a joint study of privately operated premises in Tayside revealed the following major incidences of poor practice:

o 89% exercised no administrative control on the number of sessions/customer

o 81% failed to give adequate advice to customers

o 59% maintained no customer records

o 33% displayed no guidance to users

The recent change by many commercial operators to adopt more powerful UV lamps using shorter wavelengths has led to even greater concern amongst health professionals. An assessment by the Photobiology Unit at the University of Dundee Ninewells Hospital concluded that "all tanning units are potentially harmful and that the newer stand-up type has a much greater risk than has been generally appreciated.

Scottish Executive Proposal

Compel local authorities to issue licences regulating cosmetic sunbeds premises. Require providers of cosmetic tanning facilities, or equipment, to obtain a licence to operate from the local authority. The licensing conditions would be set so that local authorities could:

o Prevent the use of sunbeds by children

o Protect adults from over-exposure

o Ensure that sunbed users are supervised

o End the use of coin-operated machines

o Ensure that sunbed sessions are monitored and limited

o Provide health risk information in sunbed parlours

o Inspect premises

The proposal seeks to achieve a number of objectives. By providing health risk information it aims to ensure adults are equipped to make informed choices about the risks of sunbed use. The conditions of licensing would require staff to be on premises, which would help to prevent overexposure to ultraviolet light, especially by those who are more sensitive such as users with fair skins. Reduce the number of burns and accidents currently attributed to the misuse of unsupervised equipment and would drive up standards amongst operators. Premises not holding a licence would not be permitted to trade.

The lack of sunbed regulation in commercial premises and the damaging impact this can have, is best illustrated by example.

In the summer of 2004, two young boys aged 11 and 13 years old used unsupervised sunbeds in Stirling and were so badly burnt, they had to be admitted to hospital. Stirling Council environmental health officers were alerted to investigate the incident but because there was no legislation covering the regulation of sunbeds, action could not be taken against the salon for being un-staffed or for allowing young people under the age of 16 years to use a sunbed.

Impact of Licensing Scheme

It is anticipated that those businesses which could not meet a licensing requirement would be required to either invest in their businesses or be forced to cease trading. This would also eliminate the existence of coin-operated sunbed machines as well as the presence of un-staffed locations.
The cost of a licensing scheme must be balanced against the cost of reducing the harm caused by sunbeds. Although there would also be an administrative charge to operators of premises, in the long run the regulations would reduce the number of Scots - presently around 7,000 per year - who are being treated for skin cancer by the National Health Service.

Conclusion

Scotland needs to take action to tackle skin cancer and the public health message that sunbeds are potentially dangerous needs to be heard loud and clear. A system of licensing for sunbed salons could do for skin cancer what the health warning on packs of cigarettes has done for lung cancer.
It would introduce health controls in an otherwise very unregulated area, it would protect our young people and children from harm and it would raise public awareness of the dangers of skin cancer.

It is suggested that the voluntary regulation scheme is ineffective, and there may be a need for formal regulation in this area. Regulating sunbeds to ensure that children do not use them and to ensure that all users are aware of the risks associated with sunbed use, could be a major step forwards in the drive to control Scotland's skin cancer epidemic.

Reference Material: (If you have a deeper interest)

1. Statistical Information Team Cancer Research UK (2006) 'CancerStats, Malignant Melanoma-UK'Information available online at http://info.cancerresearchuk.org/cancerstats/

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9. WHO fact sheet : Sunbeds, tanning and UV exposure, March 2005, at http://www.who.int/mediacentre/factsheets/fs287/en/

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13. Lim HW, Sunlight, tanning booths and Vitamin D, J Am Acad Dermatol 2005;52;868-76

14. British Medical Association- http://www.bma.org.uk

15. REHIS calls for Executive Action on Sunbeds, poor standards putting Scots at risk,November 2003

16. Ross, R. & Phillips, B. Twenty questions for tanning facility operators: a survey of operator knowledge. Can J Public Health 85, 393-6 (1994)

17. Moseley, H., Davidson, M. & Ferguson, J. A hazard assessment of artificial tanning units. Photodermatol Photoimmunol Photomed 14, 79-87 (1998).

18. Culley, C. et al. Compliance with federal and state legislation by indoor tanning facilities in San Diego. J Am Acad Dermatol 44, 53-60 (2001).

19. Moseley, H, MDavidson and J Ferguson. (1999) "Sunbeds and the need to know" British Journal of Dermatology. 141: 573-609

20. Royal Environmental Health Institute survey, November 2003 [cited in note 2].

21. NHS Scotland - Survey of Sunbed Salons in Scotland. Information collated by Royal Environmental Health Institute of Scotland, 3 Manor Place, Edinburgh, EH3 7DH, November 2003.