A Multi-Level Investigation of US Indoor Tanning PolicyEnactment, Implementation, Compliance, Impact, and Economics

皮肤癌是一个重大而昂贵的公共卫生问题，约有500万美国人以100万美元的成本接受治疗。 每年超过80亿元29.黑色素瘤是最致命的皮肤癌，其发病率在2000年增加了两倍多。 30，31.室内晒黑（IT）是黑色素瘤和角化细胞癌的一个公认原因8- 12,20-22,32.室内皮肤也更容易晒伤3，4，33，这是皮肤癌的主要危险因素9，14 -19。 大多数青少年开始IT作为青少年或年轻的成年人31。为了减少IT并保护这一风险人群， 现在有两种监管方式。首先，各州限制未成年人访问或要求父母 同意/陪伴34.其次，食品和药物管理局（FDA）试图将IT的危害降至最低 设备（例如，防护眼镜、会话持续时间限制）35.尽管未得到充分利用36， 限制和税收在减少其他风险行为方面相当成功， 吸烟37.最近的证据表明，更严格的IT法律，如年龄限制（与父母同意法或 没有法律）与较少的青年IT 38，39相关。不幸的是，执行和遵守IT法律 variable and insufficient变量和不足28，40 -44.在倡导更严格的法律或执法时， 关注可能成为进一步限制障碍的次级效应。这些障碍包括 IT法律的经济影响，可能导致小企业组织起来，反对进步的IT法律， 保护他们的经济利益，并避免在沙龙之外使用IT床（例如，家庭，公寓， 体育馆）管理不善或检查不严45-50.本五年R 01的目标是使用混合方法 多[策略]流和RE-AIM 51，52框架53提供的方法，以调查三个特定的 目标。目的1是一个比较案例研究，以阐明信息技术立法的通过过程。Aim 2使用伪- 赞助人（联盟）评估、全国调查和档案数据，以调查立法执行情况， 也就是说，沙龙和非沙龙中的法规遵从性以及与政策严格性的遵从性的关联 和执行规定41以及青少年和年轻人中的IT和晒伤结果。目标3 将前两个目标的数据与外部数据相结合，以评估与政策相关的经济影响 IT严格性、强制性和合规性的可持续性。科学的前提是 就如何将资讯科技政策转化为严格的资讯科技法例及法规遵从事宜进行研究，以及 其影响54，55，如对黑色素瘤风险因素（IT，晒伤）和继发性影响的积极结果 （经济成本，补偿性晒黑）。这种全面、多层次、严格的分析结果将为 信息技术政策干预以及其他卫生政策领域，并指导增加信息技术法律的最佳做法 严格性，走向IT“残局”56、57。这些措施可能包括在父母同意法中增加年龄限制 或将年龄限制提高到19或21岁，类似于烟草。作为相关内容和方法的专家， 领域，我们的Multiple-PI领导的团队已经准备好进行这项创新的开创性研究。

Skin cancer is a significant and expensive public health problem, with ~5 million Americans treated at a cost of over $8 billion annually 29. Melanoma is the deadliest skin cancer, and its incidence has more than tripled in the last four decades 30,31. Indoor tanning (IT) is a well-established cause of melanoma and keratinocyte carcinomas 8- 12,20-22,32. Indoor tanners are also more likely to experience sunburn 3,4,33, a major risk factor for skin cancer 9,14-19. Most tanners begin IT as teens or young adults 31. In order to reduce IT and protect this at-risk population, IT is now being regulated in two ways. First, states restrict access by minors or require parental consent/accompaniment 34. Second, the Food and Drug Administration (FDA) attempts to minimize harm from IT devices (e.g., protective eyewear, session duration limits) 35. Although underutilized36, legislation such as age restrictions and taxation has been quite successful in decreasing engagement in other risky behaviors such as smoking 37. Recent evidence suggests that more stringent IT laws such as age bans (vs. parent consent laws or no law) are associated with less youth IT 38,39. Unfortunately, enforcement and compliance with IT laws are variable and inadequate 28,40-44. When advocating for more stringent laws or enforcement, it is also important to attend to concerns about secondary effects that may be barriers to further restriction. These barriers include economic impacts of IT laws that may cause small businesses to organize and oppose progressive IT laws to protect their financial interests, and tanners switching to use IT beds outside of salons (e.g., homes, apartments, gyms) that are not well-regulated or inspected 45-50. The goals of this five-year R01 are to use a mixed-method approach informed by the Multiple [Policy] Streams and RE-AIM 51,52 Frameworks 53 to investigate three specific aims. Aim 1 is a comparative case study to elucidate the IT legislation adoption process. Aim 2 uses a pseudo- patron (confederate) assessment, national survey, and archival data to investigate legislation implementation, i.e., regulation compliance in salons and non-salons and the association of compliance with policy stringency and enforcement provisions 41 as well as IT and sunburn outcomes among adolescents and young adults. Aim 3 integrates data from the first two aims and external data to assess economic effects relevant to policy sustainability of IT stringency, enforcement, and compliance. The scientific premise derives from the paucity of research on the process of translating IT policy efforts into stringent IT legislation and compliance, as well as their effects 54,55, such as positive outcomes on melanoma risk factors (IT, sunburns) and secondary effects (economic costs, compensatory tanning). Results of this comprehensive, multi-level, rigorous analysis will inform IT policy interventions as well as other health policy arenas and guide best practices for increasing IT law stringency, moving toward an IT “endgame” 56,57. These could include adding age bans to parental consent laws or increasing age bans to 19 or 21, similar to tobacco. As experts in the relevant content and methodologic domains, our Multiple-PI led team is well-poised to conduct this innovative, seminal research.