The CITY100 (Correlates of Indoor Tanning in Youth) project assesses factors that may influence use of indoor tanning by adolescents (10,14); 1 objective is to better understand current legislation that pertains to indoor tanning. In the current study, we targeted the most populous city in each of the 28 states to evaluate how state laws are enforced at the local level.

Our goal was to interview, by telephone, the person who was the most knowledgeable about enforcement practices in each city or county. From a list of contacts for each state's legislation presented on a Web site operated by the tanning industry (15), we telephoned these contacts (typically at the state or county health department) and asked them to identify the best key informant. The process for identifying each city's respondent continued until we found a knowledgeable potential respondent. We then mailed an introductory letter to each potential respondent that explained the purpose of the study and its voluntary nature and assured anonymity of the respondent and that data would not be linked to the city's name in any published reports. Approximately 1 week after mailing the letter, we attempted to contact informants until we reached them and they completed the interview. The 2 interviewers (K.D.H. and L.C.P.) had previous experience in conducting telephone interviews and received training for this study.

The survey questions were based on a combination of previous study in this area (16), expert opinion about measuring enforcement activities in the tobacco control area (a good model for indoor tanning), and select enforcement and monitoring activities mentioned in the indoor tanning laws (14). Initially, we developed a longer version of the survey that asked for specific data on various activities (eg, number of facilities inspected in the previous year, number of complaints received). That version assumed a high level of inspection and other enforcement activities, assumed that enforcement agencies kept detailed records of those activities, and requested that informants obtain that information before the interview and provide it during the interview. During the informant identification process, we became aware that the level of enforcement activities was fairly low. Therefore, to better match the depth of our assessment to actual practices, reduce the amount of work required of respondents, and achieve a higher response rate, we retained only the basic items and eliminated the more elaborate, labor-intensive items.

The following factors were assessed: number of staff allocated to carry out enforcement activities in the city/county; whether indoor tanning businesses were required to have a license; frequency of inspections (in absence of a complaint); whether inspections were announced in advance; whether inspection included review of customer records and, if so, whether customer's age, parental consent forms, number and dates of tanning sessions, and duration of sessions were examined; and whether businesses received citations when they violated the law. We also assessed the types of penalties for selling sessions to underage youth or not obtaining parental permission for minors and whether graduated penalties (more severe penalties for each successive violation) were used. A copy of the survey is provided in the Appendix.

A draft of the survey was reviewed for clarity by 2 public health department professionals. All survey procedures and materials were approved by the institutional review board at San Diego State University. Interviews were conducted in April and May of 2007.

Descriptive statistics, including frequencies or means, were computed for each variable. Additionally, we conducted bivariate tests (χ² and correlations) to assess the associations between the stringency of the written law (14) and reported enforcement practices. Specifically, we examined the relationship between reported inspection frequency and overall law stringency score, youth access subscore, enforcement subscore, and 1 individual inspection item. For the items about penalties specific to youth access, we computed frequencies for only the 21 cities in states with youth access laws. We did not perform multivariate tests because of the small sample size. All analyses were conducted in SPSS 13.0 (SPSS Inc, Chicago, Illinois).

We identified 28 respondents (1 for the most populous city in each of the 28 targeted states) who confirmed that they were knowledgeable about enforcement practices. Data were obtained for all 28 cities. If respondents told the interviewer that their states had no law (n = 5) or that the cities engaged in no enforcement activities (n = 2), the interviewer contacted additional informants to confirm that laws were not enforced. The interviewer then coded the remaining survey items to indicate nonperformance of enforcement activities.

More than three-fourths of the respondents were employed by a state or local health agency (Table 1). The organizations that employed the respondents also constituted the primary enforcement entity for the state indoor tanning legislation in the designated city.

The number of full-time employees available for inspections and other enforcement activities ranged from 0 to 15, with a mean of 3.29 (standard deviation 3.89) staff and a median of 2. Approximately 29% of the cities had no full-time enforcement staff (Table 2). Licensure for indoor tanning businesses was required in most cities. Slightly less than half of the cities gave citations (ie, penalties) to tanning facilities that violated the state law. Approximately 32% of the cities did not inspect indoor tanning facilities for compliance with the state law, and another 32% conducted inspections less than annually. Of those cities that inspected, most conducted unannounced inspections.

Of the 19 cities that conducted inspections, most reviewed customer records as part of the inspection process. Of these, most reviewed information about customers' ages, parental consent forms, number and dates of tanning sessions, and tanning session duration (Table 3).

Of the 21 cities in states that had youth access laws, approximately half penalized these violations (Table 4). Warnings, monetary fines, and license suspensions were used for both kinds of youth access violations, with no strong predominance by type of penalty. Of the cities that penalized violations, most gave graduated penalties for each of the youth access–related violations, in which each additional violation results in a larger penalty.

We conducted Pearson correlational tests between inspection frequency and the variables from an earlier assessment of state indoor tanning laws (14). These correlations (N = 28) were 0.51 (P = .006) for enforcement subscore, 0.34 (P = .075) for minor's access stringency subscore, and 0.58 (P = .001) for overall law stringency score. Reported inspection frequency was positively correlated with the number of full-time enforcement staff reported by the respondent (r = 0.48, P = .011). We then dichotomized reported inspection frequency (less than annually vs at least annually) and the individual inspection item score from the earlier analysis of state laws (less strict vs more strict). These variables were significantly associated (χ² = 5.18, P = .023). Of cities whose laws on inspections were less strict (n = 21), only 23.8% conducted inspections at least annually. Of those whose inspection requirement was stricter (n = 7), 71.4% conducted inspections at least annually. A license requirement in the written law was significantly associated with actual (self-reported) license requirement (χ² = 5.06, P = .024). In cities in which the state law did not mention licensure (n = 6), 50% required licensure, whereas in cities whose law mentioned licensure (n = 21), 90.5% required licensure.