Sunbeds and skin cancer risk: quantifying a baseline estimate of sunbed facilities in South Africa prior to implementation of sunbed regulations

Introduction In 2009, ultraviolet-emitting tanning devices, i.e. sunbeds and tanning booths, were officially classified as carcinogenic to human health (Group 1) by the International Agency for Research on Cancer. Methods Here, we aim to estimate South African-based facilities with indoor tanning services advertised in the printed Yellow Pages and online in two directories. Printed Yellow Pages telephone directory beauty salon facilities listings (2010-14) for all provinces were examined and those mentioning "sunbed" and/or "tanning bed" recorded. Beauty/spa facilities were also identified using two sunbed listing webpages. Results A total of 40 web-advertised facilities had a sunbed. Beauty facilities in the Yellow Pages specifically mentioning sunbeds declined by 62% between 2010 (n=53) and 2014 (n=20). Gauteng had the highest number of facilities (n=25) with a sunbed. Facilities with sunbeds exist in South Africa, as evidenced by the Yellow Pages and web-advertised data, but their true prevalence remains largely unknown. It is likely that online and walk-by advertising is increasingly more common than print. Conclusion Given that sunbeds may likely soon become regulated in South Africa, further research is needed to better quantify sunbed provision, determine advice provided by facility operators to new users, investigate whether age restrictions or limits exist for sunbed use, and describe typical patterns of sunbed use in South Africa.


Introduction
Sunbed use is a risk factor for skin cancer, including cutaneous malignant melanoma (CMM), basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) [1]. In 2009, the International Agency for Research on Cancer (IARC) classified sunbeds as "carcinogenic to humans" [2]. The World Health Organization (WHO) recommends against the use of tanning devices for cosmetic purposes, but recognized the need for guidance to reduce the risks associated with their widespread use [3]. Several jurisdictions have implemented regulatory control of sunbed use, [4] including the city of Auckland in New Zealand [5] and all states in Australia, except the tropical Northern Territory, which has no sunbeds [6]. Controls implemented include a range of strategies from an outright ban, through ensuring the training of operators to warning signs and labels disclosing the associated risks [3]. Full bans have been implemented in Brazil and Iran [4]. Age limit bans exist in several jurisdictions of Canada as well as in Finland, Denmark, France, Germany, Spain and several other countries according to the worldwide sunbed legislation database [4].
In South Africa, skin cancer accounts for one-third of all histologically-diagnosed cancers [7]. Personal exposure to solar ultraviolet radiation (UVR) from the sun is a known risk factor for skin cancer; other risk factors include fair skin, a history of sunburns, dysplastic moles, precancerous skin lesions, a family history of skin cancer and a person history of skin cancer [8]. Africa experiences relatively high solar UVR levels almost all-year round.
High UVR levels combined with an outdoor lifestyle may account, in part, for the relatively high incidence of skin cancers in South Africa.
In the Western Cape, for example, the age-standardised incidence rate of new registered cases of CMM is estimated to be as high as  [7]. While we do not know whether CMM incidence, in part, in South Africa is attributable to sunbed use, international evidence suggests that this is likely [1]. Since 2013, the Cancer Association of South Africa has been working with the National Department of Health to support the implementation of sunbed regulations in South Africa.
Given that sunbed use is associated with skin cancer and there was anecdotal evidence that commercial sunbeds existed in South Africa, this raised the research question, "what is the prevalence of sunbeds in South Africa" At present, South Africa has no legislation or code of practice governing indoor tanning and associated vertical or horizontal equipment, and the number of sunbeds advertised as available for use in the indoor tanning industry was unknown. This study aimed to assess the prevalence of indoor tanning facilities with sunbeds at health and beauty facilities for commercial use by the public. This was done in two parts, to document: 1) from 2010 to 2014, the number of health and beauty facilities by province/region that specifically mention "sunbed" and / or "vertical sunbeds" (referred to collectively as sunbeds) in their Yellow Pages advertisements; and 2) by province, the number of facilities with sunbeds advertised in 2015 in two web listings of indoor tanning facilities. In so doing, an estimate of the number of facilities offering sunbed services was determined, for the first time, and, by comparison of the two datasets, differences in advertising patterns of indoor tanning facilities were explored.

Yellow Pages data
The printed (hard copy, not online Yellow Pages) beauty facilities pages from all 19 Yellow Pages-defined regions of South Africa were also categorized by province.

Analysis
The cleaned Yellow Pages data in MySQL database format and the web-advertised dataset from EpiData 3.

Yellow Pages
In 2010, a total of 53 facilities nation-wide specifically advertised as having sunbeds were listed in the Yellow Pages telephone directories (Table 1)

Discussion
Unequivocal evidence supporting the association between sunbed use and skin cancer, together with the IARC classification of sunbeds as carcinogenic to human health, have led to an increase in sunbed surveillance [10,11], regulation [12] and research [13,14].
No study has reported sunbed distribution in South Africa, to date.
The Yellow Pages audit followed Makin et al [15] and Jopson and In response to objective 1), we found that the number of facilities offering sunbed services in South Africa advertised in the printed Yellow Pages was relatively low (the calculated rate per 100 000 Caucasian population was 1. There is a possibility that, since there is no beach in Gauteng, sunbeds are an alternative option to acquire a tan before a summer holiday at the coast, or when people cannot go to the beach or on vacation to acquire a tan.
This study protocols did not include telephoning all of the listings to confirm whether or not they did have a sunbed as specified in their advertisement. The study also only focused on sunbeds; none of the other indoor tanning services, such as spray tanning, were included since the study rationale focused on the risk of sunbed use in relation to skin cancer development. The study did not consider commercial sales or hire of sunbeds, however, these services do exist in South Africa, for both commercial and home-based use. We were not able to access from the company the printed Yellow Pages data for "health and fitness centres" or hairdressers where sunbeds may be available because some of these data were not digital and required resources which we did not have in order to be scanned.
We did note several facilities advertised in the online listings were located inside a gym or fitness centre.
This study is likely to have underestimated sunbed prevalence in South Africa. It is possible that advertising of indoor tanning facilities is often opportunistic with store front signage to attract  Despite interrogating sunbed advertising as best we could, we still know little about the prevalence and use of indoor tanning facilities in South Africa;  Further sunbed use and sun exposure research is recommended to combat skin cancer in South Africa.