The hot topic of tanning
Humans value outward appearance highly, but tanning for the purposes of fashion is a relatively new practice.
Historically, aesthetes tended to favour paler skin until the post-industrial era.
From here, the popularity of tanning rose in modern Western culture, eventually giving rise to the commercial development of solariums.
As the medical implications of this change in practice emerged, Australia has emerged as a world leader in the health community’s response to the popularisation of tanning and solariums.
A short history of tanning
Much can be derived and assumed from the tone and colour of a person’s skin. It may hint at racial background, occupation, leisure choices or economic status.
There are many examples of deliberate skin-whitening throughout history.
Perhaps the most notorious was the 16th-century obsession with the cosmetic ceruse, supposedly favoured by Queen Elizabeth I herself.
This potent mix of white lead and vinegar unfortunately led to skin damage, hair loss and poisoning, alongside the more desirable effects of a milky white, unblemished complexion.
Preoccupation with white skin was commonplace prior to the industrial revolution, when pallor hinted at a life away from manual labour and a darker skin tone suggested long hours spent working in the sun.
The industrial revolution changed this by moving the working classes from the fields into the factories that were springing up across England, and later, the world.
The confines of mines and factories did not allow the occupational sun exposure seen in the early 1700s.
The smog and pollution that accompanied industrialisation also drove people indoors during their leisure time, and both combined to loosen the association between skin melanin content and socioeconomic status.
Along with the shift of the working classes indoors, the health-related aspects of sun exposure were starting to be appreciated.
In the 1890s, Dr Theobald Palm, a Scottish physician, observed that children deprived of sunlight developed rickets and was instrumental in the discovery of UV’s role in vitamin D metabolism and bone health.1
At a similar time, Dr Niels Finsen, an early proponent of phototherapy, first developed a carbon arc lamp for treatment of lupus vulgaris with UV radiation.
This earned the Danish physician a Nobel Prize in Medicine in 1903.
These early adopters of sunlight in medical therapy ushered in a new era, termed the Sunshine Movement, where medical practitioners endeavoured to boost sun exposure in the masses.
With the post-industrial shift in perceptions about class and skin tone, and potential health benefits coming to light, the stage was set for a major change in society’s perception of tanning.
The event that seemed to spark a significant shift in attitudes was, anecdotally at least, the misadventures of Coco Chanel on a beach holiday in the south of France in 1923.
Whether deliberate or accidental, the tan with which she returned from the French Riviera led to a popular obsession with sunbathing and deliberate tanning.
In the subsequent decades, doctors and the wider public noted the associated increase in sun damage and skin cancer.
The tanning lotions of the 1950s gave way to the early sunscreens of the 1970s.
Parallel to this, sun beds (popularised and brought to the commercial masses by German scientist Friedrich Wolff) returned to fashion with the promise of a controlled, safe and private indoor tanning solution.
The rise of melanoma in the West
Coinciding with popular perceptions of tanned skin and increased use (and access) to indoor tanning equipment, malignant melanoma rates are on the rise.
The WHO estimates around 132,000 new cases of malignant melanoma are diagnosed worldwide every year and Australia has the dubious honour of having the highest incidence globally.2
The reason behind this is likely multifactorial, with latitude, reduced ozone layer and a high population of fair-skinned individuals all suggested to play a part.
Social perceptions of tanning and miles upon miles of beautiful beaches upon which to sunbathe also contribute.
Today, the evidence is clear and there are widespread public awareness campaigns about the link between tanning and malignant melanoma.
A large 2009 review confirmed both recreational sun exposure and sunburn to be strong predictors of melanoma at any distance from the equator.3
In 2009, the WHO International Agency for Research on Cancer (IARC) classified ultraviolet radiation — including tanning devices — as a group 1 (definite) carcinogen.
This placed solariums in the same group as asbestos, HIV, mustard gas, plutonium and of course, smoking.
However, despite the strong messages from public health groups and cancer awareness charities, sun bed use remained a popular pastime well into the 21st century, particularly in younger members of society.4,5
According to the IARC, adolescent users are likely to be at greatest risk from the carcinogenic properties of UV exposure.6
Nationally, malignant melanoma was the third most common cancer in men (behind prostate and bowel) and women (after breast and bowel) in 2017.7
However, it is actually the most common cancer in Australians aged 15-39. It is also the most common cause of cancer death in the same age group.7
Want to go deeper? Read our CPD-accredited How to Treat module: Strategies for the early detection of melanoma
The ban on solariums in Australia
In the context of the high incidence, high rates of early cancer deaths and increasing public awareness of malignant melanoma, the conditions were right for an outright ban on a perceived preventable source of UV exposure — solarium use.
A landmark 2008 paper fuelled growing concerns over the high use of solariums among young people.
This estimated that 281 new cases of malignant melanoma in Australia per year were attributable to solarium use. There were an associated 43 deaths from malignant melanoma.
The author estimated the cost to the health system was around $3 million.8
The case of a single individual did much to push forward reform in the solarium industry of Australia.
Clare Oliver was just 26 when she died from an aggressive melanoma in Melbourne and articles published at the time of her death linked the cancer to solarium visits in her early 20s.9
Clare Oliver died from an aggressive melanoma in 2007. Photo: AAP
Her death in 2007 was followed by regional regulations in 2009 that required indoor tanning businesses to provide information on skin cancer, and exclude people under the age of 18 and those with fair skin.
A 2011 study suggested that regulation of the industry was producing decent results when compared with voluntary codes of practice, but noted inadequate compliance when excluding high-risk skin groups and those willing to lie about their age.10
The study suggested an absolute ban and this approach was ultimately adopted by legislators over the coming years.
A ban on commercial solariums was introduced from 1 January 2015, covering SA, Victoria, Queensland, Tasmania, NSW and the ACT, but omitting the NT (where there were no commercial solariums to ban) and WA.
The latter state brought in the ban on 1 January the following year.
Around the time of the ban, a government-backed buy-back scheme offered up to $2000 to solariums, but the budget for re-purchasing came in significantly under cost, indicating that many businesses sought alternate means of disposal.
The sun beds themselves are not illegal, but offering them in a commercial business setting is punishable by fines of up to $44,000.
Concerns that solariums would end up in third-party hands, servicing an unregulated black market were compounded by low rates of prosecution under the new laws.
However, as of August 2016, Jake Martin-Herde became the first person to be fined with operating a commercial solarium, indicating the ban is starting to gain traction.
Where does Australia stand in global opinion towards solarium use?
Australia stands out on the world stage in its stance towards commercial tanning — indeed, only one other country has instigated an outright ban.
In 2009, Brazil became the first country to introduce a general ban on solariums.
Brazil’s health regulatory agency stated the ban was based on the WHO IARC classification of UV radiation as a grade 1 carcinogen, alongside the failure of a voluntary code of practice in the country.
The Brazilian ban outlawed trade in artificial tanning devices and their use.
Other countries have limits on solarium use with age and parental consent.
The US in particular has high rates of indoor tanning.11 Many states have now passed laws that restrict those under the age of 18 from accessing indoor tanning services.
Canada and much of Europe have banned or restricted indoor tanning access for adolescents.
The situation in New Zealand mirrors the voluntary code of practice period in Australia, where salons are requested to turn away under 18-year-olds and those with fair skin or identified as high risk.
Similar to the Australian experience, New Zealand surveys have found low levels of compliance.
The impact of solarium bans
With the strict Australian solarium ban in place, the onus is now on epidemiologists to assess the impact of this healthcare intervention on malignant melanoma rates.
Recent data suggest a stabilisation or even a slight decline in the treatment of melanoma in those under 45 in Australia.
However, it is probably too early to be seeing a true drop in the incidence of a complex disease thanks to the legislation.
Other factors to be considered in this apparent reduction include school level awareness programs.
In addition, the actual number of cases of malignant melanoma is expected to increase despite the health campaigns and solarium ban because of the impact of cumulative and remote sun damage.
Clearly ongoing data collection is needed to see the true effect of removing solariums from the equation.
Despite widespread public awareness about malignant melanoma, the desire to maintain a ‘healthy’ tan is ingrained in some Australians, who are moving back to the beaches or seeking alternative tanning options.
It is still legal in Australia for an individual to own and use a private sunbed.
There is also a growing underground market trading in commercial solariums, which is gaining momentum with the help of social media advertising.
Fake tanning is already an incredibly popular way to obtain a golden glow, but this is a short-lived, messy, often costly, and labour-intensive method of obtaining the desired change in skin tone.
Tanning pills — oral canthaxanthin supplements — have been in use for decades to give a more golden glow.12,13
The active ingredient is closely related to beta-carotene, the substance that gives carrots their orange colour.
However, it discolours the palms and soles, which may be viewed as unacceptable by individuals wanting an authentic looking tan. Despite this, it remains relatively popular.
Further research in the area of tanning and sun protection is currently aimed predominantly at the latter, with the CSIRO funding research into coral-derived sun protection factor from the Great Barrier Reef.
This may also be of interest to people who prefer not to use conventional sunscreen due to fears about the risk of carcinogenesis from both chemical and reflective sunscreen ingredients.
Perceptions towards tanning are still evolving.
Despite a commercial ban on solariums in many countries, sunbed use remains high across the globe, particularly in North America and Scandinavia.
It remains to be seen whether the outright ban in Australia can further impact the already stabilising incidence rates of malignant melanoma.
This difference may become startling in the next 10 years, as those most vulnerable to UV exposure benefit from this additional protective measure.
Dr Dodds is an emergency medicine registrar, practising in Sydney, NSW. She is also an Associate Clinical Lecturer at the University of Sydney.
Dr Aldred is an emergency medicine senior RMO, practising in Sydney, NSW. He also has a PhD in molecular genetics.
References on request.