Tattooing regulations in U.S. States, 2011.

By | January 12, 2014

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Introduction

Humans have been decorating their bodies to express religious

beliefs, cultural values, and personal aesthetics for thousands of

years. Although initially less common in Europe and the U.S., the past

200 years have seen major shifts in tattooing: the electric tattoo

machine, polymer-based pigments, and ease of access to equipment have

led to tattoo shops becoming common throughout the Western world. The

history and technical practice of tattooing have been described in

detail elsewhere (Goldstein, 2007; Sperry, 1991, 1992) and are outside

the scope of this article.

The majority of legally acquired tattoos are done by using a

vertical vibrating electric tattoo machine and pigments purchased or

created for the purpose. The design of a tattoo is limited only by the

artist’s imagination and the client’s willingness to submit to

the procedure, and millions of U.S. residents have gotten tattoos. This

article examines existing state laws and regulations and focuses on

standards protecting the health and safety of clients during tattooing

procedures to determine whether tattooing practice is effectively

regulated across the U.S.

Studies rarely have assessed the prevalence of tattooing among U.S.

residents and populations are often not comparable. In the U.S.,

estimates among different populations vary widely, from 18% among

patients at a spinal clinic in 1991 and 1992 (Haley & Fischer,

2001), to 36% among military recruits in the late 1990s (Armstrong,

Murphy, Sallee, & Watson, 2000), and 23% among college

undergraduates in 2001 and 2006 (Mayers & Chiffriller, 2007; Mayers,

Judelson, Moriarty & Rundell, 2002).

In 2003, an online poll by Harris Interactive concluded that the

prevalence of tattooing among all U.S. adults is 16%, with substantially

higher prevalence rates among certain age cohorts (Sever, 2003). In

2006, the Pew Research Foundation estimated that 36% of all U.S. adults

aged 18-25 years and 40% aged 26-40 years had tattoos (Pew Research

Center for the People and the Press, 2006). The same year, a

random-digit-dialed survey of 500 U.S.-resident men and women aged 18-50

years found a 24% prevalence of tattoos (Laumann & Derick, 2006). By

combining 2008 U.S. Census population estimates (U.S. Census, 2009) with

available data on tattoo prevalence, at least 40 million U.S. residents

have one or more tattoos and have been at risk for a tattoo-associated

medical complication during their lifetime.

Complications of tattooing include infections transmitted during

unsanitary tattoo procedures, allergies or adverse reactions to tattoo

pigment, and coincidental lesions that appear on the skin surface

covered by a tattoo but are not caused by the tattoo procedure (Jacob,

2002). Although no reliable estimates exist for the frequency with which

complications of tattooing procedures occur, the risk of adverse effects

can still be reduced by ensuring sanitary shops and equipment,

comprehensive training of artists, and strong infection control

practices (Armstrong, 2005; Armstrong & Fell, 2000; Armstrong &

Kelly, 2001).

The most commonly identified complication of getting a tattoo is

infection during healing (Antoszewski, Sitek, Jedrzejczak, Kasielska,

& Kruk-Jeromin, 2006; Greif, Hewitt, & Armstrong, 1999).

Potential transmission of bloodborne or dermatologic pathogens is

possible if the tattoo needle or skin surface is not sterilized; many

studies have documented infectious disease transmission during tattoo

procedures (e.g., leprosy [Ghorpade, 2002], ringworm [Brancaccio,

Berstein, Fisher, & Shalita, 1981], hepatitis [Nishioka &

Gyorkos, 2001], and warts [Ragland, Hubbell, Stewart, & Nesbitt,

1994]). Extensive review of the infectious disease complications

associated with tattooing is available in Armstrong and Kelly (2001),

Kazandjieva and Tsankov (2007), and Papameletiou and coauthors (2003).

Adverse reactions to almost every color and type of tattoo pigment

have been reported as isolated case studies in the scientific literature

(Ashinoff, Levine, & Soter, 1995; Bjornberg, 1963; Bonnell &

Russel, 1956; Duke, Urioste, Dover, & Anderson, 1998; Gallo, Parodi,

Cozzani, & Guarrera, 1998; Loewenthal, 1960; Nguyen & Allen,

1979). Although tattoo pigments are considered to be cosmetics in the

U.S. and should require approval under the Food, Drug, and Cosmetic Act

of 1938, pigments are approved for topical use only, and studies testing

their safety for intradermal use have not been completed (Armstrong

& Fell, 2000; U.S. Food and Drug Administration, 2009). National and

international studies on the exact chemical composition of tattoo

pigments have yielded inconclusive assessments of the long-term effects

of intradermal placement, and further research is needed (Engel et al.,

2008; Lundsgaard, 2002; Papameletiou et al., 2003). A discussion of the

specific research needed, however, is outside the scope of this article.

Medical case reports documenting noninfectious tattoo-associated

illnesses and dermatologic complications are uncommon, but do exist

(e.g., skin papules [Kluger, Muller, & Gral, 2008; Lubeck &

Epstein, 1952], malignant melanoma [Kircik, Armus, & Vandenbroek,

1993; Kirsch, 1969], and pseudolymphoma [Kahofer, El Shabrawi-Caelen,

Horn, Kern, & Smolle, 2003]). Isolated case reports also exist of

ferromagnetic tattoo pigments causing complications for patients

undergoing magnetic resonance imaging (Kreidstein, Giguere, &

Freiberg, 1997; Wagle & Smith, 2000), although other research has

questioned this premise (Tope & Shellock, 2002).

States have regulated tattooing for decades in an attempt to

address public health concerns. In 1978, Maine became the first state to

regulate tattooing (Braithwaite, Stephens, Sterk, & Braithwaite,

1999). Stauter (1988, 1989) reported that 19 states regulated tattooing

in some way, including three that banned the practice altogether

(Mississippi, Oklahoma, and South Carolina). Six years later, Tope

(1995) reported that 29 states were regulating tattooing, including

seven banning the practice (Connecticut, Florida, Indiana,

Massachusetts, Oklahoma, South Carolina, and Vermont).

No clear guidance existed for states developing tattoo regulations

until NEHA published Body Art: A Comprehensive Guidebook and Model Code

(NEHA, 1999). The model code was written by an interdisciplinary

collaboration of stakeholders, including university faculty members,

public health professionals, medical doctors, representatives of

professional organizations, environmental health professionals, and body

art practitioners. The model code provided detailed guidelines and

recommended regulations on two of the three areas that are deemed as

having the most public health impact–sanitation and infection control.

Artist training was addressed by NEHA by specifying that artists should

have training in sterilization procedures, anatomy, and infection

control.

In 2005, Armstrong published a comprehensive review of body art

regulations enacted through September 20, 2003, which reported that 39

states (78%) had body art legislation in place (Armstrong, 2005).

Armstrong’s 2005 article concluded with a call for comprehensive,

strongly enforced body art regulations. This call was echoed

internationally by Noah (2006) and by Vasold and co-authors (2008).

Given that persons who want a tattoo are likely to obtain one regardless

of the safety considerations or costs (Armstrong & Murphy, 1997),

ensuring that existing regulations support safe tattooing practices and

that health inspectors enforce those regulations effectively are

important public health concerns.

Methods

Tattooing laws and regulations were downloaded from state

legislatures’ and enforcing agencies’ Internet sites March

1-May 31, 2011; only laws and regulations enacted at the state level

were included in this analysis (Table 1). To quantify the existing laws

and regulations and make a standardized determination of the quality and

strengths of each state’s rules governing tattooing, a 10-item

checklist was created for each of the three types of rules (sanitation,

training, and infection control) with the greatest public health impact

as identified by Armstrong’s three papers (Armstrong, 2005;

Armstrong & Fell, 2000; Armstrong & Kelly, 2001) (Table 2). The

30 items were chosen on the basis of a literature review, items included

in the NEHA model code, initial review of state laws and regulations,

and the researchers’ knowledge of tattooing practice and infection

control.

Categories were scored independently. A state’s laws and

regulations were classified as effectively regulated if they scored

[greater than or equal to]7 on all three categories, moderately

regulated if they scored [greater than or equal to]4 in all three

categories, and minimally regulated if they scored

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