Tanning addiction: current trends and future treatment

Skin cancer is the most common yet preventable form of cancer in the world. Exposure to ultraviolet radiation (UVR) – through the sun or indoor tanning machines – has been identified as the principal avoidable risk factor for the development of melanoma and non-melanoma skin cancer [1,101]. As a result, this past year the WHO’s International Agency for Research on Cancer elevated tanning beds to its highest cancer risk category – ‘carcinogenic to humans’ (Group 1) [2].

Despite overwhelming evidence linking UVR exposure to the development of skin cancer, exposure to the sun and indoor tanning machines continues to increase [3]. Additionally, multiple studies show that despite repeated health warnings and increased knowledge about the dangers of excessive UVR exposure, many individuals, particularly adolescents and young adults, continue to use minimal skin protection outdoors and when visiting tanning salons [4].

This continued purposeful exposure to a known carcinogen suggests that factors besides lack of knowledge are driving individuals to tan. Many report that the desire for a tanned appearance is the strongest motivation for sunbathing and tanning bed use [4]. However, tanners also report other benefits, such as mood enhancement, relaxation and socialization [5]. It has been suggested by the popular media and suspected by dermatologists for years that one reason tanning is so popular is that UV light is addictive.

It is easy to see why tanning would be compared to other substance dependencies. Common substances of abuse and addiction, such as smoking and alcohol, are prevalent among adolescents and young adults, are often initially perceived as image enhancing and use is continued despite knowledge of dangers. The reported benefits of mood enhancement and relaxation with frequent tanning are also consistent with addiction. Furthermore, many frequent tanners report difficulty in quitting tanning.

What do we know about tanning addiction & dependence to date?

Recent research now furthers the theory that excessive tanning can indeed be due to an addiction to UV light. High-risk tanning behavior shows signs of both dependence (physiologic dependence) and addiction (psychological dependence).

When a substance causes physiologic dependency, repeated use induces adaptive changes, characterized by tolerance (need to increase the dose to obtain the desired effects) and withdrawal symptoms upon discontinuation [6]. One way this occurs is through increased opioid receptor agonsim, which UV light may be able to cause.

A 2006 study used naltrexone – an opioid antagonist – to induce symptoms of withdrawal in frequent tanners. In this study, 50% of frequent tanners given naltrexone before UVR exposure exhibited withdrawal symptoms, including nausea and jitteriness. These symptoms were not observed in any of the infrequent tanners given naltrexone in the study [7].

Another study found that frequent tanners were able to distinguish between UV and non-UV light-emitting tanning beds that otherwise appeared identical [8]. The tanners in this study showed an overwhelming preference (95%) to tan in the UV-emitting bed. Participants in this same study suggested that UV light tanning created a more relaxed mood and even relieved their pain, possibly due to endorphin release [9].

Psychological dependence refers to the effect of a substance on the brain’s reward system and its memory of the rewards. The production of sensations of pleasure or wellbeing causes cravings and encourages repeated use [6]. This can lead to compulsive relapsing use despite negative consequences. Many frequent tanners report relaxation and mood-enhancing effects as their motivation for tanning, suggesting the possibility of psychological dependence.

Also supporting the idea of psychological dependence to tanning, one study reported that 21% of 14–17-year-old indoor tanners self-report difficulty quitting. Quitting was most difficult for those who had started tanning at an early age [10]. Adolescents who were 13 years or younger when they started tanning found it more difficult to quit indoor tanning than individuals who were 16–17 years old when they started. Teens who tanned more frequently also had more difficulty quitting indoor tanning.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the official guide to diagnosing mental disorders published by the American Psychiatric Association, defines substance dependency as having three or more of the following symptoms in a 12-month period: tolerance, withdrawal, difficulty controlling use, negative consequences, significant time or emotional energy spent, putting off or neglecting other activities and desire to cut down [11].

A tool used clinically to diagnose substance-related disorders is the Cut Annoyed Guilty Eye-Opener (CAGE) questionnaire [12]. The tanning-modified CAGE questionnaire includes four questions: Have you ever felt you needed to cut down on your tanning? Have people annoyed you by criticizing your tanning? Have you ever felt guilty about tanning? Have you ever felt you needed to tan first thing in the morning (eye-opener)?

Many recent studies have also shown that a number of frequent tanners score positively on the CAGE questionnaire, meeting criteria for having a substance-related disorder with respect to UV light. In one study, 18% of undergraduate students surveyed in Washington state, USA, who admitted to purposely tanning their skin, scored positively on the CAGE questionnaire [5]. These students also demonstrated difficulty in controlling use by admitting to continued high-risk tanning behavior despite adverse personal experiences, such as blistering, sunburns and family history of skin cancer. This percentage is comparable with the 18% of drinking college students who scored positively on the CAGE questionnaire with respect to alcohol in a Midwest study [13] and the 16% of college students who reported smoking cigarettes daily in a NIH study [14].

A survey of beachgoers in Texas, USA, found 26% of sunbathers met tanning-modified CAGE criteria and 53% met tanning-modified DSM-IV-Text Revision diagnosis for dependency with respect to UV light tanning [15].

Indoor tanning is also associated with other behavioral health risk factors, such as smoking, alcohol use, recreational drug use and eating disorders [16]. All these findings warn us that frequent tanning can lead to unhealthy dependence or addiction in some individuals.

What should be done to avoid a tanning addiction?

Prevention of an addiction is far better than trying to break one. There have been numerous intervention studies and public health attempts at increasing awareness about the hazards of overexposure to UVR. Many of these studies targeted the general population. The best approach to early primary prevention should include public education targeting young children, adolescents, their parents and caregivers. Targeted patient education may also prove helpful. Childhood preventive behaviors learned early in life will more typically be practiced later in adulthood [17]. Seatbelt use while in automobiles is a good example of this.

Further prevention of tanning addiction may be enhanced by indoor tanning legislation that prevents use by minors. Since childhood/adolescent tanning is linked to more difficulty in quitting, banning indoor tanning in children may help prevent the habit from developing. A total of 31 states in the USA currently have some form of legislation in place [102].

Treatment of a tanning addiction

If tanning addiction has already been established, this is where we need to tap in to the knowledge of human behaviorists who have studied addictive behaviors and how to treat them. As with cigarette and alcohol use, a clinician’s identification of and counseling about excessive tanning may improve the chances of behavior change. For greater likelihood of success, it is important for the clinician to suspect serious problems with tanning early and take a nonjudgmental, yet nonpassive, attitude. In counseling on any addictive behavior, it is best to put emphasis on the goals that can be accomplished, and take a positive and hopeful attitude early in treatment.

Even with a proactive and positive approach, however, behavioral change can be very difficult. There is agreement among behavioral scientists that interventions designed to modify lifestyle behaviors should involve motivation strategies and take into account the fact that individuals may be at different stages of readiness to change their behavior.

The Transtheoretical Model is widely used and describes specific stages of change [18]. It presumes that individuals move through five different stages when changing their behavior. During precontemplation, an individual has no intention of changing a certain behavior. In contemplation, an individual is considering a behavioral change but has not made a commitment. In the preparation stage, a decision has been made to change the actual behavior within a given period of time. In the action stage, a behavior change has occurred but it is still uncertain whether the change will be persistent. Maintenance is the fifth stage, after sustaining the behavior change for at least 6 months, and is categorized by relapse prevention.

When working with someone to change behavior, the goal is then to help them progress from one stage to the next. There are multiple studies that support using information about the stages of change in relation to tanning to more effectively reduce high-risk tanning behavior [19–21]. Interventions should be designed to increase the pros and decrease the cons of decreased tanning, and increase self-efficacy in dealing with challenging situations.

Finally, even if an individual reaches maintenance and is able to abstain from high-risk tanning, relapse is very common in all addictions. Relapse is typically triggered by one of the following three conditions: re-exposure to the addictive substance, stress or a context that recalls prior use. Therefore, tanners should be counseled to discover and avoid high-risk relapse situations, such as avoiding other tanners and tanning environments, minimize stress if possible and receive support from family and friends. Although not studied in the case of tanning, naltrexone, an opiate antagonist, has been helpful in lowering relapse rates over the 3–6 months after cessation of drinking, apparently by lessening the pleasurable effects of alcohol. Studies indicate that it reduces alcohol craving when used as part of a comprehensive treatment program [22–24]. This may be yet another area where we can direct future research in the treatment of tanning addiction, a growing public health problem.

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.