The reason for tattooing was usually for ceremonies and/or religious beliefs. For example, the Maori people of New Zealand were renown for their facial tattoos. The women received certain facial tattoos as a rite of passage into womanhood (8). The Baiga women of Madhya Pradesh, India also performed tattooing as a puberty ritual (9). Tattoos also showed tribal rank, as in the Ainu people of Western Asia and in Polynesia (4).

Culture and time has changed, and so has the opinion of tattoos. For instance, Pope Hadrid I banned the practice in 787 AD in Rome, claiming it was a Abarbarian practice@ (7). It wasn=t until 1691 that tattooing emerged in Western Europe in a Acivilized= society and began its acceptance. In the late 1700=s, Captain Cook brought tattoos to the South Sea Islands and presented it as a trend to the men and women of his upper-class audience (4).

All that time, the tattooing procedure was practiced by hand, as a long and tedious sitting (4). It wasn=t until 1891, when Samuel O=Reilly patented the first electronic machine. His invention stimulated more growth of tattooing in the western countries, such as in the United States (4).

Within the last 20 years there has been a tremendous increase in the amount of tattoos being given, according to the increase of tattoo ink sales in the United States (9). Many role models, music legends, and sport icons have tattoos, including Dennis Rodman, James Brown, Johnny Depp, and Sean Connery (4). It also seems not to be the fact that someone has a tattoo, but how many. It=s more accepted to have tattoos now and the tattoo industry is loving the business.

Today, body piercings are used by various tribe societies for decorations and for some ceremonies (14). The creativity of body piercing has interested many sub-cultural groups of developed countries, including groups in the U.S. (12). The popularity of the nose, eyebrow and naval piercings has amplified the creation of more artistic forms of body piercing, instead of the traditional earlobe piercing (12). Now in the U.S. it is common to see piercings anywhere on the body including the lip, chin, and tongue (3, 12).

As mentioned before, the practices of body art are increasing and the public should be aware of the risks and also be protected from as much of the threats as possible. Because of the growth in the body art industry, there can be more problems resulting. For example, Sperry states that 25% of all 15 to 25 year olds are tattooed (15). With this statistic, one should keep in mind as to how much knowledge a 15 to 25 year old has on the threats body art can pose to them. There=s a possibility that this aged population is only concerned with the design, cost, and placement of the new body art. With this dramatic increase in body art services, there needs to be some sort of protection for the customers in a regulatory aspect.

There are two separate occurrences where the bacterial infection can take place. The first is if the piercing was done in a poor sanitary technique or using unsterile equipment. The other is during the aftercare procedure, if the body art is not kept clean or protected as directed (11). If the tattooist follows appropriate cleanliness procedures, and the receiver takes proper care of it afterwards, the risk of bacterial infection at the site would be minimized (15).

Non-Infectious Health Complications. Not only can the actual body art procedures cause medical complications, but so can the ingredients of the inks or the mixture of metals present in the jewelry (2, 5, 26). Tattoo pigments may cause allergic reactions (5). These tattoo pigments can contain elements such as cadmium, cobalt, chromium, copper, iron, titanium, and zinc (2). In addition, the uptake of inks in the lymph nodes is well known, but the long-term effects have not been explored to a high degree and remain unknown (5). Moreover, there is a record of a woman that had to undergo an MRI (magnetic resonance image scanning), and because of her tattoo, had medical complications during the procedure. She complained of feeling a burning pain in her back at the area of her tattoo as soon as it began. It turned out that one of the dyes in her tattoo contained enough iron oxide that two droplets of it could have been pulled across a table with a common horseshoe magnet (27).

Another concern brought up is the jewelry used in body art. If the ingredients contain nickel or brass plating, it tends to produce allergic or infectious responses, or a metal allergic dermatitis (2, 11). Jewelry should be made of gold, stainless steel, niobium, titanium, platinum, or a low porosity plastic to eliminate these responses (2, 27, 28). Furthermore, both Dr. Botchway, of the Alberta Dental Association, and Drs. Price and Lewis of the American Dental Association, state that oral piercings can result in tooth fractures, keloid scarring, and airway obstruction (28, 29). With these health threats, one can now understand the importance of regulating the body art industry to protect the public health from potential hazards.

Controversially, although inks are being injected into one=s skin during the tattooing procedure, the Food and Drug Administration (FDA) fails to regulate them (2, 5, and 19). They are considered to be color additives and carry a cosmetic label, with the approval to be topically used (2). AThe purity and identity in inks are mostly unknown,@ writes Anderson, a physician at the Massachusetts General Hospital (5). One ingredient, mercury, was once used in red tattoo ink. The mercury was found to cause red reactions to many people. Even though it is no longer used, the red reactions still occur (26). This may be caused by an unknown ingredient that has not been discovered yet. There are, however, regulations by the FDA on the needles used in tattooing (19, 21). Yet, the ingredients should be a concern to the FDA because of the other potential health complications which dyes can have on one=s skin and/or health.

In addition to the lack of regulation of purchasing equipment and the ingredients used, there is also a concern as to how they are purchased. For example, most inks are sold in bulk amounts and the tattooist pours the amount he predicts to use (2). However, if the ink is not all used up, then the ink is usually saved and poured back into the larger container; resulting in a possible contamination of the whole batch. A safer approach would be to remove a smaller amount of pigment into a single-use disposable container, and discard leftovers to eliminate contamination of the whole batch (2).

Environmental agencies at local, state and national levels have proposed some regulation of tattoo artists, establishments, equipment and materials (5, 19). In 1986, NEHA, National Environmental Health Association, organized a board to put together a model code guideline book, which was finally released in 1998 (2, 30). It was called the NEHA Body Art Model Code and Guidelines Book (2, 30). It was distributed to each state in hopes of promoting consistent regulations that might be adopted throughout the nation (2). The format of this guideline, however, is very strict to the instruction and regulation of body art. The NEHA approach is primarily to set rules, conduct inspections, and fine when not in compliance; which is referred to as the command-and-control approach (30, 31).

There seems to be an assumption that command-and-control regulation and compliance activities, such as licensing, inspecting and establishing standards, will directly reduce risks or at least prompt change in practice that leads to risk reduction (1, 31, 32). AIt seems, relative to environmental protection, that there is often a tendency to equate process with outcome,@ says Wiant (1). Having stricter, more severe rules tend to give the impression that more complying will be accomplished as far as regulating is concerned. However, environmentalists have criticized this method, proposing intervention in these practices to reduce regulations and encourage voluntary incentives as rewards for risk reduction (1, 31, 32).

The more severe the rules and control, the less cooperation an establishment may offer. These stringent regulations can sometimes be contrary to environmental objectives, as well (31). In other words, the enforcing agent is more concerned with fining and tickets then having compliance and safety for the public. The NEHA Body Art Code Book is a very fastidious and particular approach. Even though that method may eventually prove to be the most productive, there may be more effective alternatives (1).

Kris Sperry M.D. and tattooist Mick Michieli-Beasley, created the Alliance of Professional Tattooists (APT) to educate tattooists in proper infection control practices (15). Professional members receive certificates and display them at their establishment. To become professionally certified by the APT, a tattooist must have three years experience at an established location, and take a PDTT class (Preventing Disease Transmission in Tattooing). An ATP professionally certified tattooist could then post their certification in the establishment, marketing their credentials. The alliance can sometimes be more flexible than some regulations given by local and state health departments. But the APT=s primary concern is to keep the art of tattooing safe and legal through education, knowledge and awareness. It actively monitors legislation in preventing tattooing from being over-regulated, controlled or banned (33).

In many health and environmental issues, one size does not fit all the circumstances (1). What needs to be done is to achieve better environmental results by the use of flexible approaches, stressing education, awareness and knowledge, and to make it easier for companies to comply with the help of incentives and rewards for voluntarily hazard prevention (31). The more severe the regulatory forces, the less respect, acceptance, and cooperation the regulated population will offer.

I feel the best approach would be to fuse educational and flexible approach ideas with command-and-control approaches. One of the most important factors in regulating body art industry is in education and awareness (33). The key to achieving a safe body art establishment is to teach the distributors of the dangers associated with body art and to encourage voluntary prevention (1, 32). Furthermore, linking the command-and-control methods of regulation with the voluntary approaches could be a more suitable approach (32). This might not only lead to a safe body art establishment, but a reputable one as well.