Indoor tanning: an emerging public-health concern

Tanning controversies

For years, dermatologists have been warning their patients and the public of the risks associated with excessive UV light exposure. UV radiation is a proven carcinogen [101], responsible for more than half of all human malignancies [1]. Treating these extremely common cancers is very costly to our society [2]. Total annual direct costs in the treatment of melanoma and nonmelanoma skin cancers are estimated to be almost US$300 million and $1.5 billion, respectively [102]. Over time, UV radiation exposure results in cutaneous photodamage, compromising skin function and appearance. Skin rejuvenation therapy, measures designed to undo the effect of UV radiation overexposure, is a $35 billion a year industry [3]. UV overexposure is a major, avoidable and extremely expensive health hazard.

The tanning industry, which generates a revenue of $5 billion/year from approximately 30 million US citizens [4], spends large sums of money on lobbyists and media campaigns trying to counter these health warnings [103]. The Indoor Tanning Association, a powerful special interest group that represents owners of tanning businesses, disputes connections between skin cancer and tanning beds [104]. They argue that more UV exposure, and therefore indoor tanning, is healthly and reduces the risk of multiple diseases [105]. The argument is based on the contention that vitamin D deficiency, which can be aggravated by a lack of adequate sun exposure, can be diminished with tanning bed use. The Indoor Tanning Association also tries to augment their argument for tanning bed use by stating that UV exposure helps fight depression and eases skin conditions such as psoriasis, acne and eczema.

There is no doubt that vitamin D is important for human health. Rickets, manifesting with growth retardation and skeletal abnormalities in children, was the first disease described where sunlight was shown to have a beneficial treatment effect. In the early 1900s, vitamin D was discovered and milk fortification essentially eradicated the rickets epidemic among children in Europe and the USA [5]. Since then, more recent studies are indicating other potential ways that vitamin D may benefit human health. There are studies to suggest vitamin D can help prevent bone fractures in the elderly, multiple sclerosis, rheumatoid arthritis, Type 1 diabetes, and perhaps even cardiovascular disease and cancer [6–12]. However, there is a significant amount of variability in the opinion of what constitutes hypovitaminosis D, and there is variability in the actual measuring and reporting of serum vitamin D levels [13]. There are also studies that suggest an opposite effect, that vitamin D may adversely affect human health. One such study demonstrated that vitamin D supplementation in infancy increased the risk of atopy and allergic rhinitis in adulthood [14]. It is clear that we do not have all the answers when it comes to vitamin D and what roles it plays in disease prevention.

It is also important to acknowledge that some groups are at an increased risk of vitamin D deficiency. These groups include the elderly, individuals who are housebound or are in institutional care, darkly pigmented individuals, individuals who cover their skin for cultural/religious reasons, and exclusively breastfed infants (particularly darkly pigmented infants) [3,15,16]. In addition, patients that have to protect themselves against UV radiation for medical reasons, including patients with xeroderma pigmentosum, basal cell nevus syndrome, lupus erythematosus or transplant recipients, are potentially at risk of developing vitamin D deficiency. In darkly pigmented individuals, melanin actually absorbs the UV photons that would otherwise generate vitamin D, so safe amounts of UV light exposure generally do not correct vitamin D deficiencies [17]. For individuals with medical conditions that make UV radiation dangerous, tanning beds cannot safely help correct vitamin D deficiencies.

Even if the extra exposure needed to raise vitamin D levels was safe in vitamin D-deficient populations, the indoor tanning industry is not targeting these groups. Rather, they are targeting fair-skinned teenagers and young adults: those at highest risk of UV photodamage. Salons do not advertise at nursing homes or infant day care centers. They advertise on university campuses. Models portrayed in tanning advertisements are not generally physically disabled or of African–American descent. They are young, naturally fair-skinned individuals with deep bronze coloring. The most frequent clients of tanning salons are not from groups at risk for vitamin D deficiency, they are healthy Caucasian teenagers and young adults [15].

The unsuspecting consumer of tanning salon services may be completely unaware that indoor tanning devices emit UV radiation levels far greater than natural sunlight. The author’s previous study of tanning facilities throughout the state of North Carolina (USA) found that the average amount of UVA and UVB emitted from the devices was equal to four-times and two-times the amount, respectively, emitted during noon-day sun in Washington (DC, USA) [18]. In very short periods of exposure, patrons using these devices can receive significantly more UV radiation compared with that from the sun.

The reality is that indoor tanning devices lead to UV radiation damage and health risks [19]. At the same time, the so-called health benefits of using an artificially generated carcinogen (in the form of an indoor tanning device) are not well supported scientifically [15]. The only well-established health benefit of UV irradiation is vitamin D photosynthesis, and it has been estimated that sun exposure of 5–15 min a day, three times a week, can boost vitamin D to healthy levels. Vitamin D levels can also be increased from diet and dietary supplements [3]. Because of this, most of us in the healthcare profession believe the risks of indoor tanning far outweigh the benefits.

Higher risk tanners

The amount of UV light that frequent tanners are exposed to puts them at increased risk of developing skin cancer. Youth represents an especially critical period during which UV radiation increases skin cancer risk [19]. Melanoma, the most deadly form of skin cancer, has become one of the most common cancers among adolescents and young adults, according to the American Cancer Society [106]. For young women aged 15–29 years, rates of melanoma have increased more than 60% since the mid 1970s. At this point, many studies have documented the skin cancer risk associated with tanning-device usage. For these reasons, reducing UV exposure and altering tanning behavior of minors is a prime target of skin cancer prevention efforts.

As indoor tanning is such a potential health hazard, there are certain groups of tanners we are particularly concerned with. Studies have shown that a number of individuals who frequent indoor tanning salons show signs of having a substance-related disorder. Our recent study demonstrated that 18% of undergraduate students who admit to purposely tanning their skin scored positively on the CAGE (Cut Down, Annoyed, Guilty, Eye-opener) questionnaire, indicating the probable existence of substance related disorder with respect to UV light [20]. Another study reported that 21% of 14–17 year old indoor tanners self-report difficulty quitting, mostly teens who had started at an early age and who frequently tanned [21]. UV light has also been shown to cause endorphin release, similar to other pleasure-seeking behavior. Furthermore, frequent tanners get withdrawal symptoms when given naltrexone, a drug that blocks a narcotic-like substance produced in the skin during tanning. But infrequent tanners who take naltrexone do not get withdrawal symptoms [22]. In another study it was found that UV exposure is a relaxing and reinforcing stimulus in frequent indoor tanners [23]. Further research has demonstrated that indoor tanners are often tobacco and alcohol users as well [24]. All these findings make it more probable that frequent tanning leads to unhealthy dependence or addiction in some individuals.

Some indoor tanners have also been diagnosed as having body dysmorphic disorder, a condition involving excessive preoccupation with a minor or imagined defect [25]. According to the National Institute of Mental Health in Bethesda (MD, USA) body dysmorphic disorder can be chronic and may lead to repeated hospitalizations and even suicide. It can also result in decreased social, academic and occupational functioning.

Adolescents in particular are susceptible to unhealthy excessive tanning behaviors and are at risk for developing one of the conditions described previously. Adolescence is a time of increased self-awareness, self-identity, self-consciousness, preoccupation with image and concern with social acceptance [26]. Adolescent girls are especially apt to experience decreased feelings of attractiveness and self-esteem [27]. These factors make adolescents more susceptible to social pressures and prevalent media messages promoting the bronze, tanned look.

Future policy considerations

Despite the tanning industry’s efforts to the contrary, all evidence indicates the necessity of stricter indoor tanning industry regulations and restrictions on use by minors. As a society we have banned other known carcinogens. This is not unprecedented. Just as for cigarette laws, these proposals are attempting to stop kids from developing a risky habit. The controversial message that one should use a tanning bed to prevent cancer is like saying one should inhale cigarette smoke to get their daily intake of oxygen or chew tobacco to get their daily requirement of minerals. Excessively exposing oneself to a known carcinogen to obtain a health benefit seems extremely counterintuitive.

Regulations proposed to date are not trying to ban tanning altogether. Of the few states that have comprehensive safety regulations, most require children or teens to bring along a doctor’s prescription, notarized parental consent or parental accompaniment to the tanning salon [28]. Interestingly, the majority of surveyed tanning bed operators felt that written parental permission should be required to use indoor tanning devices [29]. These measures are a great start; however, there will still be children who manage to get these consents as they are compelled by popular media to tan their skin. If we were to heed the advice of the WHO, we would completely prevent the use of indoor tanning by minors.

Another target for future efforts will be to enlist the increased help of the media, as they have helped toward these efforts in the past, and to further portray tanning as an unhealthy behavior, rather than a healthy one. Perhaps as a society we should also consider a ban on marketing and advertising the sale of indoor UV carcinogens to our youth.

Another intriguing consideration would be to restrict the sales of artificial radiation to those businesses that specialize solely in tanning. In the author’s previous study in North Carolina, the ‘tanning only’ businesses had better profiles when it came to measuring compliance with FDA safety recommendations [18]. Furthermore, in some states these businesses are required to update annual licenses, and to get initial and on-going operator-safety training. If we are going to allow this industry to continue offering a carcinogen to the public, it should be done in the safest and most responsible way possible. Many studies have documented that tanning bed operators have a significant lack of knowledge regarding the use of these devices as well as the potential adverse health effects, so we need to make them more accountable [30,31]. A beautician focusing on cutting somebody’s hair may not know enough about the health effects of UV overexposure, and furthermore may not be paying very much attention to how much time a client is spending in the tanning device. The use of timers, of course, helps control this issue, but timers do not always work properly, or may initially be set too high.

Although it may be years before we may see significant decreases in purposeful indoor tanning of the skin, we need to continue to focus on ways to increase safety and prevent harm.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.