Addicted to Tanning

Addiction to Indoor Tanning: Relation to Anxiety, Depression, and Substance Abuse
Mosher CE, Danoff-Burg S
Arch Dermatol. 2010;146:412-417

Dermatologists like to compare recreational indoor tanning with smoking, and with good reason. Both are acquired behaviors linked to the development of life-threatening malignancies (malignant melanoma and lung cancer, respectively). Moreover, both represent risk factors that, at least superficially, appear to be completely avoidable. No one can alter his or her genetic make-up, but why not just quit smoking or tanning?

Smoking, of course, is hard to quit because it is a substance-related disorder (SRD) — an addictive behavior that is characterized by behavioral and physiologic dependency. Recently, Warthan and others have asserted that the same holds true for ultraviolet light tanning.[1,2] Now, Mosher and Danoff-Burg present compelling evidence that, for a significant subset of young adults, indoor tanning may indeed be more of an addiction than a choice.

How is an SRD defined? Mosher and Danoff-Burg used 2 well-established SRD measures: the 4-item CAGE (“Cut down, Annoyed, Guilty, Eye-opener”) questionnaire that is commonly used to screen for alcoholism, and a tanning-specific modification of the 7 SRD criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Both screening tests were self-administered by 421 college student volunteers (67.5% women; 93% between 18 and 21 years old) recruited from a university in the northeastern United States during the fall of 2006.

Of this cross-sectional pool, 237 participants (56.3%) reported that they had tanned indoors at least once in the past, and 229 of these completed their questionnaires. Participants who reported a long-term history of indoor tanning visited tanning salons a mean of 23 times during the previous year. Not surprisingly, habitual tanners were far more likely to meet criteria for addiction to tanning than were nontanners or sporadic tanners. Intriguingly, tanning “addicts” were also more likely to report symptoms of anxiety and substance abuse.

Specifically:

Among the 229 study participants who had used indoor tanning salons, roughly one third met SRD criteria for addiction (30.6% met CAGE criteria; 39.3% met DSM-IV-TR criteria).
Students who met criteria for indoor tanning addiction reported greater symptoms of anxiety than those who did not meet the criteria.
Students who met criteria for addiction to indoor tanning or addictive tendencies also reported greater alcohol and marijuana use during the previous month than those who did not meet the criteria.
Almost half (42%) of students who met the criteria for addiction to indoor tanning reported the use of at least 2 substances (eg, alcohol, marijuana, cocaine, amphetamines, or opiates) during the previous month; in contrast, only 16% of students who reported never tanning indoors and 16.8% of students who tanned indoors without meeting criteria for addiction reported this level of substance abuse.
In this study, tobacco use and depression did not correlate with tanning addiction status.
Variables, such as sex, age, and skin phototype, did not appear to correlate with tanning addiction status.
Viewpoint
Evidence linking excessive ultraviolet exposure to both malignant melanoma and nonmelanoma skin cancer is now irrefutable.[3,4] In addition, habitual tanning causes premature skin aging and photodamage (dyspigmentation, skin laxity, and rhytids) and can exacerbate pigment disorders, such as melasma and postinflammatory hyperpigmentation. Although knowledge of these harmful effects has become more widespread over the past decade, the use of indoor tanning facilities is more popular than ever, especially among young adults.[5]

How can this alarming paradox be explained? Mosher and Danoff-Burg propose that habitual indoor tanning may, in some cases, be best characterized as an SRD. Indeed, roughly one third of the college students whom they surveyed met both CAGE and DSM-IV-TR criteria for addiction to ultraviolet tanning. This subgroup also showed a greater proclivity to substance abuse and anxiety, suggesting that habitual tanning may be a predictor of other addictive behaviors, such as alcoholism and cigarette smoking.[6]

Most internists have encountered patients with end-stage emphysema or terminal lung cancer who, in some cases, die quite literally with a cigarette in hand. In a similar manner, most dermatologists have patients who, despite having a diagnosis of malignant melanoma, still won’t give up their weekly trips to the tanning salon. How can this self-destructive behavior be explained? In a word: addiction. As Mosher and Danoff-Burg and others have noted, many people who habitually tan would have a hard time kicking the habit, even if properly motivated to do so.

Armed with this new knowledge, clinicians should view habitual indoor tanning for what it is: a risky, potentially addictive behavior that is reinforced by a wide range of cultural, social, and psychological factors. In this context, conquering this popular and growing addiction will require more than a few stern words of warning delivered at the end of a routine skin examination.
By: Graeme M. Lipper, MD
References
Warthan MM, Uchida T, Wagner RF Jr. UV tanning as a type of substance-related disorder. Arch Dermatol. 2005;141:963-966. Abstract
Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol. 2007;56:375-379. Abstract
Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal call and squamous cell cancers. J Natl Cancer Inst. 2002;94:224-226. Abstract
Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev. 2005;14:562-566. Abstract
Robinson JK, Kim J, Rosenbaum S, Ortiz S. Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007. Arch Dermatol. 2008;144:484-488. Abstract
Heckman CJ, Egleston BL, Wilson DB, Ingersoll SK. A preliminary investigation of the predictors of tanning dependence. Am J Health Behav. 2008;32:451-464. Abstract

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May 20, 2010. Health.

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