Compliance with restrictions on sale of indoor tanningsessions to youth in Minnesota and Massachusetts

Jean L. Forster, PhD,a DeAnn Lazovich, PhD,a Andrea Hickle, MPH,b Glorian Sorensen, PhD,c

and Marie-France Demierre, MDd

Minneapolis, Minnesota, and Boston, Massachusetts

Background: Minnesota and Massachusetts require parental permission, for persons younger than 16 or18 years of age, respectively, for indoor tanning.

Objectives: This report examines business practices and characteristics associated with sales of indoortanning to underage girls.

Methods: Fifteen-year-old girls tried to purchase an ultraviolet tanning session in 200 indoor tanningbusinesses in the Minneapolis-St Paul and Boston areas without parental consent. Business characteristicswere recorded. Later, businesses were interviewed by telephone about their facilities and practices.

Results: Eighty-one percent of businesses sold a session to an underaged buyer on at least one of two tries.Illegal purchases did not differ by state. Businesses least likely to sell were larger, dedicated to indoortanning, required employee certification, and had a minimum age of sale for their business. However,businesses in each of these categories still sold tanning sessions to underaged adolescents at 44% to 62% ofthe visits. Employees who requested parental consent or age identification almost never sold a session.

Limitations: Businesses in Minnesota and Massachusetts only were included.

Conclusion: Minnesota and Massachusetts laws specifying a minimum age of sale for indoor tanning areineffective. ( J Am Acad Dermatol 2006;55:962-7.)

Recent studies that encompass the modernindoor tanning era provide evidence thatmelanoma increases with regular use of

indoor tanning, especially among younger per-sons.1,2 In light of these findings and other healthrisks, national and international health organizations

From the Division of Epidemiology & Community Healtha and the

Center for Public Health Education & Outreach,b University of

Minnesota, Minneapolis; the Department of Society, Human

Development, and Health, School of Public Health, Harvard

University, Bostonc; and the Department of Dermatology,

Boston University School of Medicine.d

Supported by grant R01 CA079593 from the National Institutes

of Health.

Conflicts of interest: None identified.

Accepted for publication June 4, 2006.

Reprint requests: Jean L. Forster, PhD, University of Minnesota,

Division of Epidemiology & Community Health, 1300 S Second

St, Suite 300, Minneapolis, MN 55454. E-mail: forster@epi.umn.

edu.

Published online August 14, 2006.

0190-9622/$32.00

ª 2006 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2006.06.036

962

recommend avoiding all sources of ultraviolet radi-ation.3-5 However, the indoor tanning industry in theUnited States is a multibillion dollar enterprise.6 A2002 statewide survey of Minnesota adults found that45% of women (76% of women 25-34 years of age)and 30% of men had ever used an indoor tanningdevice.7 A recent review of indoor tanning useamong adolescents found that prevalence rangedfrom 2% to 11% among boys and from 12% to 37%among girls between the ages of 11 and 18 years inthe United States.8 Among 14- to 17-year-olds in theMinneapolis-St Paul metropolitan area, 12% of boysand 42% of girls reported tanning indoors.9

The Food and Drug Administration and the USFederal Trade Commission regulate indoor tanningbusiness practices. The Food and Drug Administra-tion regulations cover equipment specifications,exposure schedules, use of eyewear, and warningstatements, whereas the Federal Trade Commissionprohibits deceptive advertising of health benefitsfrom indoor tanning.10,11 In addition, 21 states reg-ulate access of minors to indoor tanning.12,13 All 21states require written parental consent to tan if the

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person is younger than 16 or 17 years of age. Eightof these states require that a parent also accompanyminors under the ageof 14 to 18 years. Six states imposea minimum age at which adolescents are allowed touse indoor tanning facilities (generally age 14).

Minnesota and Massachusetts both have state lawsthat regulate indoor tanning businesses. Massachu-setts state law requires that municipalities licensetanning businesses and that they inspect them twiceannually, and the law specifies penalties for viola-tions.14 Minnesota law includes no requirements forlicensure and provides no penalties or enforcementmechanism or authority.15 Both states require pa-rental permission to tan. In both states a parent orguardian must sign a required warning statement inperson, witnessed by an employee, before theinitial tanning session of the adolescent (age 16 yearsin Minnesota, age 14-17 in Massachusetts). Thoseyounger than 14 years of age must be accompaniedby a parent each time by law in Massachusetts.

A limited number of studies in the past 10 yearshave assessed tanning business compliance withstate restrictions on age of sale. A phone survey ofbusinesses in the San Diego, California area includeda question about whether a hypothetical 15-year-oldsister would be permitted to tan. More than 57% ofthe businesses agreed without mentioning parentalpermission, in violation of California state law.16

Another study, also in San Diego, compared theresults of a telephone interview by a minor to visits tothe same tanning businesses by a minor. In this studythe minor told the employee (on the phone or inperson) that she was 15 years old and had nevertanned before and asked the employee if a parentneeded to sign something before she tanned.Compliance with the California state law was higher,with 64.3% (in person) and 69.5% (on the phone) ofbusinesses requiring parental permission comparedwith the earlier San Diego study.17 Another studyused telephone surveys of businesses in 4 states(Texas, Illinois, and Wisconsin, which regulate ageof sale for indoor tanning, and Colorado, which hasno requirement). Tanning business employees wereasked if a 12-year-old or a 15-year-old person wouldbe allowed to tan and if parental permission wasrequired. Businesses in the regulated states weremore restrictive than Colorado, with Wisconsinbusinesses being the most restrictive, consistentwith their strong state regulation.18 The methodolo-gies for each of these studies included direct ques-tions about age of sale and thus do not directlymeasure business behavior when not prompted tothink about this issue. Therefore actual compliancewith the state law by the businesses may beoverestimated.

In the Minnesota and Massachusetts IndoorTanning Study, adolescent girls aged 15 years, whoare required by law in each state to provide parentalconsent to tan indoors, visited 200 indoor tanningbusinesses in the Minneapolis-St Paul and Bostonmetropolitan regions to attempt to purchase a tan-ning session without parental consent and withoutvolunteering their age. These businesses were laterinterviewed about their facilities and practices bytelephone. The purpose of our report is to examinewhich business practices and characteristics wereassociated with the likelihood of a successful pur-chase attempt.

METHODSSample selection

Tanning businesses in the Minneapolis-St Pauland Boston metropolitan areas were identifiedthrough Yellow Pages, Dun & Bradstreet, andAmerican Business Disc as well as through environ-mental health officials at local health departments.Businesses in Minneapolis-St Paul were also foundthrough the Office of the Secretary of State. A total of358 businesses in the Minneapolis-St Paul area and138 in the Boston area were enumerated, and the listfor each area was randomly sorted before screeningfor eligibility. Starting at the top of each list, one staffperson in each of the metropolitan areas called eachbusiness to ask if the business was (1) open to thepublic, (2) accepted walk-in customers, and (3) soldsingle tanning sessions. If the business responded‘‘yes’’ to all 3 questions, they remained in the studysample; otherwise, we replaced the business withanother eligible business until 100 eligible busi-nesses in each location were obtained.

Data collectionEach business was visited on two occasions,

approximately 2 weeks apart, by a 15-year old girlposing as a customer (the buyer). Nine adolescentsconducted the assessments; no business was visitedtwice by the same buyer. The buyers were all non-Hispanic white. Buyers followed a script, were givencash to purchase a tanning session, and carried state-issued photo identification with correct date of birth.They were instructed to answer honestly all ques-tions posed by the employee. If sold a session, thebuyers paid cash for it, entered the tanning room toobserve signage, and after a few minutes, left thebusiness without tanning, usually offering that theyhad received an urgent call on their cell phoneand had to leave. Upon returning to the car wherethe adult driver waited, the buyers completed a sur-vey that included questions about the success of thepurchase attempt, whether age eligibility was

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assessed (ie, the employee asked age, asked fordate of birth, and/or asked for age identification),whether parental consent was requested, and char-acteristics of the employee (gender, age). The buyersalso recorded business practices, such as whetherthey were asked to sign a warning statement,whether the employee inquired about propensity toburn or medications, if the employee made recom-mendations for length or frequency of tanning ses-sions or how to use the bed, availability of goggles,and evidence of signs (warnings, sanitation). Thesebusiness practices could be collected only if a sessionhad been purchased. The underaged buyers askedno questions about non-ultraviolet tanning.

On the second business visit, the adult drivers(n = 9) who had accompanied the buyers to the sitebut had remained in the car during the buyers’ visitsalso entered the business as future customers. Thedrivers proceeded to ask the employee questionsabout knowledge of health risks and business prac-tices. Health and safety questions included whether abase tan protects against sunburn, whether tanningdevices are safe, and if indoor tanning could causesunburns or skin cancer. Responses could rangefrom an affirmative or qualified response (it de-pends) to a negative or unknown response (em-ployee did not know or driver did not ask). Theseitems were coded so that a high score indicatedcorrect knowledge of health and safety (range 1 to 4;if unknown, the response for that item was set tomissing). We then created a health and safety knowl-edge score by taking the mean across items for whicha response was provided. The drivers also recordedemployee responses to 5 recommended businesspractices, including how often to tan, how to termi-nate a session, whether the business or customercleaned the beds, and if the business required and/orprovided goggles. For each response that was incompliance with state regulations, a point was givenand summed to create a responsible business prac-tices score. The proportion of correct responses inrelation to the number of questions actually asked bythe drivers was calculated (drivers did not always askevery question). For these two summary measures,businesses were grouped into high and low cate-gories according to the median value for eachmeasure.

After completion of the business visits, we at-tempted to interview the owner or manager for eachof the 200 businesses by telephone. Two businessesno longer provided tanning services at the time ofthe interview, 19.7% refused to participate, and, for11.6%, the manager was never reached, leaving 136businesses with a completed telephone interview(64 in Minnesota, 72 in Boston). We asked the

responsible individual to provide us information onthe number of years they had been with that businessand how long the business had been in operation,whether the business was part of a chain, the numberof tanning units, the number of employees and thepercentage under 18 years of age, and the percent-age of their customers that come for tanning (asopposed to other services, such as hairstyling cuts).We also inquired about associations to which thebusiness belonged, requirements for employee train-ing and the elements of the training, employeecertification, percentage of time that a manager ison the premises, a system of monitoring employeecompliance with business rules, knowledge of localordinances, and licensure to operate. Business pro-motional practices were also obtained. We collectedthose practices required by law including placementof warning signs, provision of free goggles, equip-ment maintenance and sanitation, rules for teen-agers, and whether the businesses had ever beeninspected.

All data collection methods were reviewed andapproved by the Human Subjects’ Committees ofthe University of Minnesota and Harvard UniversitySchool of Public Health.

Statistical analysisWe compared the likelihood that the buyer’s

purchase attempt was successful for businesseswith and without the characteristic of interest asreported by the business, or observed by the buyeror driver. Logistic regression was used to calculateodds ratios and 95% confidence intervals, taking intoaccount the clustering of buyers and drivers withineach city and repeated visits to each business.Characteristics associated with a successful purchaseattempt did not differ by city; therefore we adjustedfor city in all analyses, treating it as a fixed effect.

RESULTSAmong the 100 businesses in Massachusetts and

the 100 businesses in Minnesota visited twice byadolescent buyers, 81% sold a tanning session to theadolescent buyer on at least one visit, whereas 57%sold a session to the buyers on both visits; 69% ofall purchase attempts were successful (n = 400).Businesses participating in the telephone interview(n = 136) sold a tanning session more often thanthose that did not (76% vs 65%; P = .07). Businessesin Minnesota and Massachusetts were equally likelyto sell a tanning session to the adolescent buyers.The average cost of a single tanning session in thebusinesses where attempts were successful was$6.00; sessions were slightly more expensive inMassachusetts ($6.12) than in Minnesota ($5.91).

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Table I presents the business characteristics asreported by the business that are associated with thelikelihood of a successful purchase attempt. Largerbusinesses and those dedicated to indoor tanningwere less likely to sell tanning sessions to underagedadolescents than businesses with fewer beds orthose whose primary business was not indoor tan-ning. Staff certification of training to provide indoortanning services, particularly when both the man-ager and employees had been certified, also led tofewer successful purchase attempts, as did industryassociation membership. Among businesses thatreported having adolescent customers, those with aminimum age or a parental consent requirementwere much less likely than those without theserequirements to allow the adolescent buyer to pur-chase a tanning session. Even so, the probability of asuccessful purchase attempt ranged from 46.1% to61.5% for businesses reporting these requirements.

Table II reports the association between businesscharacteristics and practices observed by the buyersand drivers and sales to underage buyers. Only 8businesses asked the buyer for age identification onone visit; only one business asked for identificationon both visits. Although the probability of a success-ful purchase attempt was lowest among these busi-nesses, just asking about age or date of birth alsogreatly reduced the likelihood of a successful pur-chase attempt relative to those businesses that didnot check age eligibility by any method (49.7% vs98.3%). Employees who told the adolescent thatparental consent was needed almost never sold asession to the buyers (\1% of attempts successful)compared with almost universal success amongbusinesses that did not mention the requirement(95.8% successful). Employees perceived by thebuyer to be younger than 18 years of age or whowere male were more likely to sell sessions to thebuyers (all female). Although employee compliancewith a higher percentage of responsible businesspractices or greater employee knowledge of healthand safety for indoor tanning, as observed by thedriver, were associated with a lower likelihoodof a successful purchase attempt, neither measureachieved statistical significance.

LimitationsChief among the limitations of this study is the

possible bias introduced by activities of the tanningindustry associations. When the associations becameaware of our study, they sent letters to tanningbusinesses recommending that they not participatein the telephone interview. The 68% of businessrepresentatives who agreed to the interview arethose who either did not get the letter before the

interview or who chose to disregard the industryadvice. In addition, the study includes only metro-politan Boston and Minneapolis-St Paul tanningbusinesses; therefore it is possible that a generaliza-tion of the results outside these two areas of theUnited States cannot be made. Finally, adolescentbuyers were instructed not to lie about their age or inany other way to act older or disguise their age,strategies that might be used by teens intending totan. Despite those constraints, the buyers had no

Table I. The likelihood of a successful purchaseattempt according to business characteristics andpractices reported by 136 tanning businessmanagers who completed telephone survey

Characteristics No.*

% Purchase

attempt

successful ORy 95% CI

No. of tanningunits

1-2 32 80.7 1.003-5 26 79.1 0.92 (0.32, 2.65)6-10 51 60.5 0.37 (0.16, 0.87)101 27 44.6 0.19 (0.07, 0.51)P trend \.0001

Percentage ofcustomerswho tan

\50% 47 77.9 1.0050%-99% 32 63.8 0.50 (0.22, 1.13)100% 48 53.4 0.33 (0.16, 0.68)P trend .0003

Staff certificationz

Neither managernor employees

54 74.2 1.00

Manager oremployees,not both

26 57.8 0.48 (0.21, 1.09)

Both managerand employees

31 52.9 0.39 (0.18, 0.86)

P trend .05Belongs to an industry

associationNo 87 73.7 1.00Yes 45 51.2 0.37 (0.20, 0.69)

Minimum agerequirement§

No 80 69.5 1.00Yes 19 46.1 0.37 (0.16, 0.88)

Requires parentalconsent§

No 13 86.4 1.00Yes 86 61.5 0.27 (0.07, 1.01)

CI, Confidence interval; OR, odds ratio.

*Represents number of individual businesses.yAdjusted for city (Boston vs Minneapolis).zAsked only of businesses reporting training for employees.§Asked only of businesses that reported serving minors.

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trouble purchasing sessions, and our results likelyunderestimate actual ease of purchase by minors.

DISCUSSIONThe rate of sales of tanning sessions to 15-year-old

girls in this study was high (81%). Age was notassessed in more than 40% of the attempts, and,

Table II. Likelihood of a successful purchaseattempt according to business characteristicsand practices observed by adolescent buyerand adult driver

Characteristics No.*

%

Purchase

attempt

successful ORy 95% CI

Adolescent buyerobservation

Employee genderFemale 317 66.5 1.00Male 83 78.3 1.80 (1.01, 3.23)

Perceivedemployeeage (y)

[25 216 67.8 1.0018-25 156 67.8 1.01 (0.64, 1.59)\18 27 83.9 2.51 (0.91, 6.92)

Age eligibilityDid not assess 162 98.3 1.00Asked age, no

ID checked228 49.7 0.01 (0.003, 0.05)

ID checked 10 35.2 0.01 (0.001, 0.04)Told that parental

consent neededNo 267 95.8 1.00Yes 123 0.9 0.004 (0.002, 0.009)

Adult driverobservation

Responsiblebusinesspracticesz

Low 192 72.4 1.00High 204 66.2 0.69 (0.39, 1.20)

Knowledge ofhealth andsafety§

Low 214 72.9 1.00High 182 63.7 0.64 (0.38, 1.08)

CI, Confidence interval; OR, odds ratio.

*Represents number of buys, since the characteristic assessed

could differ from buy to buy within a business; however, analysis

was performed at the business level.yAdjusted for city and individual confederates (buyer or driver

depending on source of information).zCalculated as percentage of business-reported compliance for

those practices that the driver recorded (up to 5 practices total).§Calculated as the mean of the score across each of 4 knowledge

items.

when not assessed, sale to underaged girls wasalmost universal. It is important to emphasize thateven among businesses with characteristics associ-ated with higher compliance relative to the othercategories, the sales rate was high in absolute terms.The only practice that produced acceptable compli-ance rates was asking for parental permission (99%compliance).

We were surprised to find no differences insales to underaged buyers between Minnesota andMassachusetts, despite the more restrictive regula-tion of indoor tanning businesses in Massachusetts.Although the restrictions on youth access and otherrequirements of the laws are very similar in the twostates, Massachusetts state law requires licensureand annual inspections and specifies penalties fornoncompliance, whereas Minnesota law does notinclude enforcement provisions or penalties.14,15

A previous report showed that although environ-mental health specialists reported more regular in-spections of tanning businesses in Massachusettscompared with Minnesota, environmental healthspecialists in both states reported less specific knowl-edge of and attention to youth access provisions inthe state law compared with other areas covered bythe state laws.19

The businesses in this study actually performedworse than those in most previous studies wherecompliancewith youth access laws was assessed.16-18

Differences in methods for assessing businesscompliance may account for much of that difference,since asking businesses about their practices bytelephone raises the issue directly and their resultsmay reflect social desirability. Indeed, 46% of thebusinesses that told us on the phone that they had aminimum age for tanning sold a session to underagebuyers, as did 62% of the businesses that in thetelephone interview stated that they required paren-tal consent. Although our buyers did not lie abouttheir age and carried identification giving theircorrect age, they did not bring the issue up either,in contrast to the study by Hurd et al,17 possiblyreflecting more closely the practices of underagedteenagers seeking to tan. Undoubtedly, state differ-ences do occur, as Hester et al18 discovered whencomparing 4 states in which businesses were chal-lenged with the same protocol.

Organizations representing the tanning industryofficially encourage in training materials that busi-nesses require parental consent or parent presencefor adolescents to tan.6,20 Indeed, businesses in ourstudy that reported belonging to an industry associ-ation, participating in a staff certification program, orhaving an established minimum age of sale were lesslikely to sell to the study confederates. However,

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purchase attempts were still successful about half thetime for businesses with these characteristics. Thismay be due, in part, to the inherent conflict betweenindustry support for compliance and industry mar-keting strategies that include targeting high schoolstudents (offering free sessions to social role models,employing teenagers, holding drawings for concerttickets, making donations to high school sportsteams), and for maintaining young customers whotan primarily before an event such as the prom.21-24

The scenarios most likely to result in a sale to anunderaged buyer are strikingly similar to thoseleading to sales of tobacco to minors. In both casesmale employees are more likely to sell than femaleemployees, younger employees are more likely tosell than older employees, and checking age identi-fication rarely results in a sale to an underagedbuyer.25 In fact, access of adolescents to indoortanning mirrors the situation of tobacco sales tominors several years ago, with illegal sales almostubiquitous, and social norms not proscribing illegaluse.26 Tobacco sales to minors have declined dra-matically over the past decade in many parts of thecountry because of several factors, all of which aremore likely to lead to a request for age identificationby clerks.25,27 Stronger state and local laws thatspecify enforcement authority and penalties andfund enforcement could motivate tanning businessesto change their practices in a similar fashion.

To conclude, our data show that when the age ofadolescents is not assessed, illegal sale of indoortanning is almost universal. Significant work needsto be done at the individual and community levelsto change the social norms around having a tan, toreduce opportunities to tan indoors by changingpolicies and business practices, and to educatecommunity members about the serious risks ofindoor tanning.

We thank Ms Natania Remba and the adolescents andadults who assisted with the purchase attempts.

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