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500万美国人接受治疗，花费在 每年超过80亿美元29。黑色素瘤是最致命的皮肤癌，其发病率在美国增加了两倍多。 在过去的40年里，30，31。室内晒黑(IT)是引起黑色素瘤和角质形成细胞癌的公认原因。 12，20-22，32。室内晒黑的人也更有可能经历晒伤3，4，33，这是皮肤癌9，14-19的主要风险因素。 大多数制革工人在十几岁或年轻的时候就开始晒黑了。为了减少IT并保护这一高危人群，IT 现在受到两种方式的监管。首先，各州限制未成年人进入或要求父母 同意/伴奏。其次，食品和药物管理局(FDA)试图将IT带来的危害降至最低 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，但诸如年龄等立法 限制和税收在减少其他危险行为方面取得了相当成功，例如 吸烟37.最近的证据表明，更严格的IT法律，如年龄禁令(与父母同意法或 (没有法律)与较年轻的IT 38，39有关。不幸的是，执法和遵守IT法律是 可变和不足的28，40-44。在倡导更严格的法律或执法时，同样重要的是 注意对可能成为进一步限制的障碍的次要影响的担忧。这些障碍包括 IT法律的经济影响可能导致小企业组织和反对进步的IT法律 保护他们的经济利益，以及晒黑者在沙龙外使用IT床(例如，住宅、公寓、 健身房)没有得到很好的监管或检查，比例为45：50。这份为期五年的R01的目标是使用混合方法 由多个[策略]流和RE-AIM 51、52框架53通知的方法，以调查三个具体的 目标。目标1是一个比较案例研究，以阐明信息技术立法的采纳过程。AIM 2使用了一个伪- 赞助人(邦联)评估、全国调查和档案数据，以调查立法执行情况， 即，在沙龙和非沙龙遵守规定，并将遵守与政策严格性联系起来 和执行条款41以及青少年和年轻人的信息技术和晒伤结果。目标3 整合前两个目标的数据和外部数据，以评估与政策相关的经济影响 IT严格性、执行和合规性的可持续性。科学的前提来自于匮乏 研究将信息技术政策努力转化为严格的信息技术立法和合规的过程，以及 它们的影响54、55，例如对黑色素瘤风险因素(IT、晒伤)的积极结果和次要影响 (经济成本，补偿性制革)。这一全面、多层次、严谨的分析结果将为 IT政策干预以及其他卫生政策领域，并指导增加IT法律的最佳实践 严格性，迈向IT“终局”56，57。这些措施可能包括在父母同意法中增加年龄限制 或者将年龄禁令提高到19岁或21岁，类似于烟草。作为相关内容和方法方面的专家 在全球范围内，我们由多名PI领导的团队已做好准备，开展这项创新的、开创性的研究。

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.