By Arianne S. Kourosh, MD, and Heidi Jacobe, MD, MSCS
Decades of research and hundreds of thousands of skin cancer-related deaths have demonstrated that there is no such thing as a “healthy tan.” Despite increased public awareness of the link between skin cancer and ultraviolet radiation (UV) from both the sun and tanning beds, relatively few tanners have converted to non-UV options. Nor has the increasing number of sunless tanning products available significantly reduced UV tanning. Why not? A growing body of research indicates that for frequent tanners, a direct effect on mood may be motivating many people to lie in the sun or in a tanning bed. As with people who need a drink or a cigarette, some tanners’ feelings of elation and relief may eclipse their awareness of the threat of skin cancer and premature skin aging.1 This research raises the question: are the effects of tanning more than skin deep?
A TANNING EPIDEMIC
In the US, where the lifetime risk of developing invasive melanoma has risen to 1 in 51.2 30 million Americans visit indoor tanning salons annually, fueling a $5 billion dollar a year industry.3 Despite recent efforts to educate the public and limit young peoples’ access to indoor tanning facilities, sunbathing and indoor tanning have not significantly decreased.
Indoor tanners display a high level of knowledge about the risks of UV exposure, but this awareness does not alter tanning behavior, especially for those in their teens and twenties.4, 5,6,7 Even among melanoma-prone families, 35 percent of young adults have reported using tanning beds.8 By persisting in such behavior, tanners resemble persons with substance dependence disorders.
Researchers have developed criteria to diagnose UV light-related substance abuse based on the classic CAGE questionnaire and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). CAGE was originally created to help identify alcohol abuse; it stands for Cut Down, Annoyed, Guilty, and Eye-opener. In studies, tanners were asked if they ever felt they needed to cut down on tanning; were annoyed by criticism about their tanning; felt guilty about tanning, or needed to tan first thing in the morning. In one investigation, 70 percent of frequent UV tanners met criteria for UV light substance abuse or dependence disorders.9 Subjects have reported missing events to tan, facing social or occupational consequences because of tanning, and continuing to tan despite awareness of its threat to their health.10, 11 As with other addictive behaviors (like smoking), the younger tanners are when behavior begins, and the more frequently they tan, the greater the likelihood of dependence.12, 13
There is also evidence that some frequent tanners are self-medicating underlying psychiatric disorders. Some researchers believe excessive tanning may be a form of body dysmorphic disorder (BDD), 14 with the skin being the subject of the disorder. (Body dysmorphic disorder is a “preoccupation with a specific body part and the belief that this body part is deformed or defective. The preoccupation causes distress or significant impairment in functioning.”15) Repeated or excessive plastic surgery, for example, is a symptom of BDD.
While a desire to look tan may contribute to some disordered (extreme) tanning behavior, this does not fully explain tanning’s effect on mood and the physical dependence reported in recent studies. In our 2011 study, when we queried 100 patrons of a tanning salon regarding their reasons for tanning, two of the top three reasons were “to feel good” and “relaxation.”16
It has recently been shown that some tanners may suffer from seasonal affective disorder (SAD), a psychiatric condition consisting of depressive episodes “that occur at a certain time of the year, usually during winter.”17 In one study, 80 percent of frequent tanners reported symptoms of SAD, and investigators suspect that some tanners use UV-emitting tanning beds to improve their moods.18 (SAD is properly treated by the use of a light box that emits visible, not UV, light.) In controlled (and blinded) studies by our group19 and others, 20 subjects were unknowingly exposed to both a UV-emitting tanning bed and an identical bed from which the UV light had been filtered. When asked which tanning session they preferred, the vast majority favored the real UV-emitting bed, even though they did not know which bed this was. After exposure to the real tanning bed, tanners reported a more relaxed mood and subsequent decreased craving to tan.20
There is even preliminary evidence for the existence of UV withdrawal (distressing physical symptoms after discontinuation of UV radiation exposure), similar to the withdrawal reported for opioid drugs such as heroin. In one 2006 study comparing the effects of UV-emitting and “sham” tanning beds, researchers randomly administered either an opioid antagonist (to block the pleasurable effects of tanning) or a placebo to both frequent and infrequent tanners.21 When given the drug before tanning, 50 percent of frequent tanners reported nausea after tanning, a symptom consistent with withdrawal, while infrequent tanners experienced no symptoms.
Our own recent research19 explored the effect of UV light on the brain activity of frequent tanners. We exposed tanners who met the criteria for dependent behavior to a UV-emitting tanning bed and a “sham” one, while simultaneously using functional brain imaging. Our preliminary results indicate that exposure to the real (but not “sham”) tanning bed activated centers in the brain associated with pleasure.
Identifying tanning as an addiction changes the model for prevention and treatment. Traditional techniques of advertising the adverse consequences are likely ineffective among the individuals who are at greatest risk of addiction due either to their age or habit.4, 5,6,7,22,23 Instead, approaches similar to those used in other addictive disorders are indicated. It is also important to remember that as with alcohol and illegal drugs, addicted tanners might be self-treating underlying psychiatric disorders like SAD and BDD. These individuals should be identified and treated psychologically.
Of course, prevention is always the safest route. If you haven’t started tanning, don’t.
Dr. Kourosh is at the University of Texas Southwestern Medical Center at Dallas.
Dr. Jacobe is Assistant Professor, Department of Dermatology, University of Texas Southwestern Medical Center at Dallas. She is a member of The Skin Cancer Foundation’s Photobiology Committee.
- Tsoureli-Nikita E, Watson RE, Griffiths CE. Photoageing: the darker side of the sun. Photochem Photobiol Sci 2006; 5(2):160-4.
- National Cancer Institute. SEER Stat Fact Sheets: Melanoma of the Skin. http://seer.cancer.gov/statfacts/html/melan.html. Last updated Nov. 10, 2011. Accessed Feb. 23, 2012.
- Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol 2005; 53(6):1038-44.
- American Academy of Dermatology. Research shows popularity of indoor tanning contributes to increased incidence of skin cancer. PRNewswire. http://www.prnewswire.com/news-releases/research-shows-popularity-of-indoor-tanning-contributes-to-increased-incidence-of-skin-cancer-53497177.html Jan. 12, 2006. Accessed Feb. 27, 2012.
- Mawn VB, Fleischer AB, Jr. A survey of attitudes, beliefs, and behavior regarding tanning bed use, sunbathing, and sunscreen use. J Am Acad Dermatol 1993; 29(6):959-62.
- Robinson JK, Rademaker AW, Sylvester JA, Cook B. Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med 1997; 26(3):364-72.
- Arthey S, Clarke VA. Suntanning and sun protection: a review of the psychological literature. Soc Sci Med 1995; 40(2):265-74.
- Bergenmar M, Brandberg Y. Sunbathing and sun-protection behaviors and attitudes of young Swedish adults with hereditary risk for malignant melanoma. Cancer Nurs 2001; 24(5): 341-50.
- Mosher CE, Danoff-Burg S. Addiction to indoor tanning. Arch Dermatol 2010 146(4): 412-417.
- Warthan MM, Uchida T, Wagner RF, Jr. UV light tanning as a type of substance-related disorder. Arch Dermatol 2005;141(8): 963-6.
- Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007; 56(3):375-9.
- Vander Ark W, DiNardo LJ, Oliver DS. Factors affecting smoking cessation in patients with head and neck cancer. Laryngoscope 1997; 107(7):888-92.
- Zeller S, Lazovich D, Forster J, Widome R. Do adolescent indoor tanners exhibit dependency? J Am Acad Dermatol 2006; 54(4):589-96.
- Phillips KA, Conroy M, Dufresne RG, et al. Tanning in body dysmorphic disorder. Psychiatr Q 2006; 77(2):129-38.
- Psychiatric Disorders. Body dysmorphic disorder. AllPsych Online. http://allpsych.com/disorders/somatoform/bodydysmorphic.html. Last updated Nov. 29, 2011. Accessed Feb. 24, 2012.
- Harrington CR, Beswick TC, Leitenberger J, Minhajuddin A, Jacobe HT, Adminoff B. Addictive-like behaviors to ultraviolet light among frequent indoor tanners. Clin Exp Dermatol 2011: 36:33-38.
- Seasonal affective disorder. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002499/. ADAM Medical Encyclopedia. Last updated March 6, 2011. Accessed Feb. 28, 2011.
- Hillhouse J, Stapleton J, Turrisi R. Association of frequent indoor UV tanning with seasonal affective disorder. Arch Dermatol 2005; 141(11):1465.
- Harrington CR, Beswick TC, Graves M, et al. Activation of the mesostriatal reward pathway with exposure to ultraviolet radiation (UVR) vs. sham UVR in frequent tanners: a pilot study. Addict Biol 2011; doi: 10.1111/j.1369-1600.2010.00312.x
- Feldman SR, Liguori A, Kucenic M, et al. Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004; 51(1):45-51.
- Kaur M, Liguori A, Lang W, Rapp SR, Fleischer AB, Jr., Feldman SR. Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006; 54(4):709-11.
- Robinson JK, Rigel DS, Amonette RA. Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996. J Am Acad Dermatol 1997; 37(2 Pt 1):179-86.
- Westerdahl J, Olsson H, Masback A, et al. Use of sunbeds or sunlamps and malignant melanoma in southern Sweden. Am J Epidemiol 1994; 140(8):691-9.