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3. Borchers AT, Lee JL, Naguwa SM et al. StevensJohnson syndrome and toxic epidermal necrolis. Autoimmun Rev 2008;7:598–605. 4. Warswick S, Cotliar J. Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of treatment options. Dermatol Ther 2011;24:207–218. 5. Del Pozzo Magana BR, Lazo-Langner A, Carleton B et al. A systematic review of treatment of drug-induced StevensJohnson syndrome and toxic epidermal necrolysis in children. J Popul Ther Clin Pharmacol 2011;18:121–133. Cinzia Campagna, M.D.* Davide Tassinari, M.D.* Iria Neri, M.D.† Filippo Bernardi, M.D.* *Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy, †Department of Dermatology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy Address correspondence to Cinzia Campagna, M.D., Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, Bologna 40138, Italy, or e-mail: campagnacinzia@ libero.it.

Pediatricians’ Perspectives on Indoor Tanning Abstract: This report presents results from an online survey of New York State pediatricians regarding their counseling habits and attitudes toward indoor tanning among adolescents, as well as their awareness of current legislation that restricts youth access to tanning beds.

Several studies support an association between indoor tanning and skin cancer risk (1). A recent study estimated that one in 20 cases of melanoma are linked to tanning bed use (2). Furthermore, first exposure to ultraviolet (UV) radiation from a tanning bed before the age of 35 years may increase melanoma risk by 75% to 87% (1,2). Nonetheless, according to a 2009 national survey, 15.6% of students in grades 9 through 12 reported tanning bed use at least once in the previous year, 49.1% of whom reported use 10 times or more in a year (3). In 2012 the United States Preventive Services Task Force (USPSTF) recommended counseling fair-skinned individuals ages 10 to 24 years to reduce UV exposure (4). Furthermore, studies suggest that such counseling is effective as parents who are counseled by a primary care physician or pediatrician about sun safety are more likely to use sun protection on their children regularly and to teach them safe sun practices (5). Similarly, pediatricians and family physicians have an opportunity to educate patients and parents on the risks of indoor

tanning and may also partner in efforts to pass legislation restricting indoor tanning among youths. We distributed an email to members of Chapters 2 and 3 of the District II (New York State) of the American Academy of Pediatrics (AAP) requesting participation in an anonymous survey designed to understand pediatricians’ counseling patterns regarding indoor tanning among adolescents. The email contained a link to an electronic survey designed in SurveyMonkey that contained the following sections: responder demographics; patient demographics; attitudes toward indoor tanning, including whether parental consent should be required or a state ban implemented and at what age; patient education, including how often they counsel patients on the dangers of indoor tanning and what resources they provide; barriers to counseling; and familiarity with and interest in current legislative efforts to restrict youth access to tanning. In addition, as a comparison arm, a final section included similar questions on adolescent counseling practices with regard to text messaging while driving. The survey was distributed in July 2011. Respondents were given 3 months to respond. Five percent of those surveyed (137/2,953) responded; 86 were female and 51 male. Practice types were as follows: academic center or medical school (n = 57), group practice (n = 34), solo or two-physician practice (n = 20), currently nonpracticing physicians (n = 5), and other or no response (n = 21). “Other” included such write-in responses as residents (n = 5), fellows (n = 1), and urgent care, emergency, and subspecialty pediatricians (n = 10). Practice locations were urban (n = 76), suburban (n = 45), rural (n = 5), and no response (n = 12). Among 137 pediatricians who responded, 45% counsel at least 1% of their patients between the ages of 11 and 18 years on indoor tanning, while only 4% counsel 50% or more, despite the fact that 92% agreed that indoor tanning is an important preventive health issue. Lack of time was the most frequently cited obstacle to counseling; 59% agreed that given the limited time during a visit, other topics seem more important. Interestingly, although more pediatricians agreed that counseling on indoor tanning was a more important topic than text messaging while driving (92% vs 86%), pediatricians counsel more on the latter issue: 47% counsel at least 1% of their adolescent patients about the dangers of text messaging while driving while 16% counsel 50% or more. This discrepancy may be explained in part by other barriers contributing to a lack of counseling on indoor tanning, including limited provider knowledge of and access to information on indoor tanning health risks

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(cited by 34% of respondents) and a lack of interest among adolescent patients (cited by 23% of respondents). Solutions might include providing access to a free telephone service that helps parents counsel their teenagers on tanning dangers—an option that appealed to 69% of our respondents. Informational pamphlets may also be beneficial. In one question, respondents were asked to select all that apply from a list of various forms of counseling. Only 3% reported distributing printed materials during the visit, while 4% reported that educational materials were available in waiting rooms. Supplying pediatric offices with educational pamphlets for distribution may help circumvent the problem of time constraints for counseling. Other effective strategies to impact indoor tanning include videos in pediatric waiting rooms or outreach to teenagers through social media, such as Facebook and Twitter. Finally, given that approximately one-third of respondents cited a lack of knowledge on the topic as a barrier to counseling, formal curriculum training of pediatric residents on the health risks of UV indoor tanning and effective ways to counsel adolescents on this topic may be beneficial. For example, a recent USPSTF clinical summary suggests that certain tactics, such as appearance-focused behavioral counseling and emphasizing the aging effect of UV radiation rather than its carcinogenic properties, may be most effective with female adolescents (4). With regard to state legislation, 89% of respondents either agreed or strongly agreed that the state government should ban UV indoor tanning below a certain age. Still, the majority of respondents were uncertain whether legislation had been proposed or enacted to restrict youth access to tanning in New York State and 98% reported that they had not been contacted by advocacy groups to support such legislation. These results are surprising given that at the time of survey distribution, New York’s law required parental consent for indoor tanning between ages 14 and 17 years, effective December 21, 2010. A new bill was also under consideration in New York to require a complete ban for those younger than age 17 years; this bill passed in July 2012 (6). Our findings highlight the failure of current advocacy efforts to involve pediatricians, which is unfortunate given that 69% of respondents said they would be willing to devote 15 minutes to 1 hour toward advocacy—an adequate amount of time to write emails or letters petitioning state representatives. Thirty three states have passed youth access laws, with many more bills under consideration (6). Pediatricians may be a great asset in efforts to pass future legislation.

The limitations of this study include a poor response rate and limited demographic information for non-responders. The survey was not formally validated, although the wording for the study was selected to try to maximize clarity and minimize bias. Although our low response rate and lack of survey validation makes it difficult to extrapolate these results to the larger pediatric community, we hypothesize that our results may in fact overestimate the number of pediatricians who counsel patients on indoor tanning or are aware of related legislation, as individuals who responded to this survey may be more likely to have an interest in the topic. Despite its limitations, we believe our study highlights the need to further involve pediatricians in efforts to educate patients on the dangers of UV indoor tanning and pass further legislation to restrict its use among adolescents. REFERENCES 1. International Agency for Research on Cancer: Working Group on Artificial Ultraviolet Light and Skin Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer 2007;120: 116–1122. 2. Boniol M, Autier P, Boyle P et al. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ 2012;345:e4757. 3. Guy GP, Tai E, Richardson LC. Use of indoor tanning devices by high school students in the United States, 2009. Prev Chronic Dis 2011;8:A116. 4. Behavior counseling to prevent skin cancer. United States preventive services task force. http://www. uspreventiveservicestaskforce.org/uspstf11/skincancouns/ skincancounsrs.htm. Accessed on September 12, 2012. 5. Davy L, Boyett T, Weathers L et al. Sun protection counseling by pediatricians. Ambul Pediatr 2002;2:207– 211. 6. Indoor tanning restrictions for minors—a state by state comparison. National Conference of State Legislators, 2012. http://www.ncsl.org/issues-research/ health/indoor-tanning-restrictions-for-minors.aspx#2012_ Legislation. Accessed on September 12, 2012. Meghan T. Hession, M.D.* Shannon M. Campbell, D.O.† Sophie J. Balk, M.D.‡ Deborah L. Cummins, M.D.* *Department of Dermatology, Boston University Medical Center, Boston, Massachusetts, †Department of Dermatology, Ohio State University, Columbus, Ohio, ‡Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York Address correspondence to Meghan T. Hession, M.D., Department of Dermatology, Boston University Medical Center, 609 Albany St., Boston, MA 02118, or e-mail: meghan.hession@gmail. com.

Pediatricians' perspectives on indoor tanning.

This report presents results from an online survey of New York State pediatricians regarding their counseling habits and attitudes toward indoor tanni...
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