Dying for a Tan: A Survey to Assess Solarium Adherence to World Health Organization Guidelines in Australia, New Zealand, and the United Kingdom

MATERIALS AND METHODS

A questionnaire was developed specifically for this survey. It has not been validated but based on the International Commission on Non-Ionizing Radiation Protection and WHO recommendations. A female-simulated customer visited each of the solariums face-to-face and pretended to be a prospective customer, asking all questions that were on the proforma, and completing this after departure from the solarium. The prospective customer did not use a sunbed in any of the individual institutions. The same simulated customer was used in every tanning salon. All solariums chosen were randomly allocated from 3 major cities in the United Kingdom (London, Bristol, Manchester) and New Zealand (Wellington, Christchurch, and Rotorua) and 4 major cities in Australia (Cairns, Brisbane, Sydney, and Townsville). Twenty-one solariums were selected from each country to make a total of 63 solariums visited. We ensured that franchise businesses were not visited more than once to avoid any bias in their training regulations. All spray-tanning and coin-operated solariums were excluded from the directory list.

We asked a set of questions that were relevant to WHO recommendations. The standard questions asked included the following:

1. Do you carry out a skin assessment prior to sunbed use?

2. Can you clarify the potential side effects, given the recent public reports, in particular regarding skin cancer risks?

3. Do I have to sign a consent form?

4. Do you supply eye protection?

5. How long do I have to wait before booking my next session?

6. How long are your average sessions?

RESULTS

All of the solariums visited were compliant with the study, with 63 parlors answering all the questions.

Overall percentage of total solariums within a country that followed the regulations reveals an overall low proportion of conformity (Table 1). The standard set by our sample of solariums was highest in Australia (41%) and the United Kingdom (39%), followed by New Zealand (20%).

The regulation least satisfied was the consent form. Fourteen percent of solariums in New Zealand requested completion of a consent form, compared to 100% of solariums in both Australia and the United Kingdom. Few solariums in New Zealand adequately informed customers of the potential adverse side effects of sunbed use including skin cancer risks.

Figure 1 illustrates variable tested for each country. The variable best carried out by individual solariums in all 3 countries was the salon's ability to provide eye protection for customers.

Figure 1. Percentage of 21 solariums conforming to a sample of WHO recommendations in New Zealand, the United Kingdom, and Australia.

DISCUSSION

Despite our small sample size, our data have shown several differences in the way sunbed parlors conduct their business, with a degree of variation in each country. A plausible reason for these differences is the effect of differences in solarium regulations worldwide.¹³ Previous studies conducted in Australia in which 176 solariums were interviewed found that only 15.9% of those interviewed fulfilled 10 of the 13 recommendations by the WHO.¹³ Studies have shown little improvement in the maintenance of a safe standard of care since implementation of legislative reform.¹⁴

Solariums in New Zealand were less likely to comply with regular skin assessments, filling in consent forms and providing explanation of potential cancer risks to customers. It has been suggested that before beginning a tanning course, all sunbed operators should ensure that a consent form is signed and dated on the first visit and kept for at least 2 years in the establishment.⁵

Studies have shown that sunbed use increases melanoma risk if its use begins earlier in life.⁴ The International Agency for Research on Cancer concluded that the causal relationship between UV rays and melanoma was further increased with sunbed exposure before the age of 35 years.² This, therefore, implies that interventions should be heavily targeted toward the young adult population, those with increased vulnerability to the carcinogenic impact of indoor tanning.¹¹ There is a need to increase public awareness on the dangers of sunbed use. Education and media campaigning have been implemented with some success. Australia has been running a campaign for sun-related behavior called Sunsmart since 1988. A 15-year-long study shows a general improvement in sun-protective behavior, suggesting that protective behaviors are amenable to change with education.¹⁵ New Zealand has fewer campaigns compared with Australia, with claims that their adolescent population lacks sun protection knowledge and understanding of the threat UV light poses.¹⁶ One study conducted in New Zealand found that young individuals were unsure about the risks posed by artificial sunbeds.¹⁷ This gap in knowledge is not only unique to young New Zealanders with similar outcomes in the United Kingdom, where even fewer campaigns exist. Recent suggestions imply that tanning be considered as a form of addiction, with users exhibiting a degree of physiological dependence.¹⁸

Despite the common misbelief that sunbeds provide a “safer” method of tanning, the emission spectrum at times has been found to be 10 to 15 times greater than the midday sun in the Mediterranean.³ In this study, we measured average length of sessions as one of our variables. Tanning bed sunlamps have changed over time in the frequency of wavelengths emitted. Therefore, as a measure we suggest that this should not be interpreted as absolute, since the emission spectrum was unknown.

Our survey was limited in that it involved an interview that required yes and no answers. It was difficult to obtain proof for these claims. However, other studies have suggested that utilizing this method of visiting sunbed parlors is an effective way of assessing current legislation in Australia, as well as providing the media attention to further promote a downward trend in sunbed usage.¹⁹ To our knowledge, no other surveys have compared solarium use in different countries. Most studies have attempted to evaluate attitudes and motivations of users, with little inquiry into those entrusted as “service providers.” The continued growth in the solarium industry, coupled with the emergence of evidence suggesting adverse health effects linked to sunbed usage, highlights the need for public education. Our findings by no means conclude how each country conducts and conforms to regulations. They are a sample of solariums in each country that provide an insight into how solariums in each country conform to regulations. To provide data for comparison of each country, greater sample size and a more robust study design is needed. Despite this, they do reflect the improvements that can be made at service provider level to protect users. We have demonstrated the variation that exists between solariums worldwide and emphasizes the need for larger-scale studies. A more uniform method of service provision is suggested.