Is Tanning Addictive?
Tuesday, October 03, 2006
Despite the adverse effects of ultraviolet (UV) exposure, the
indoor tanning business is booming.1 It has been one of the fastest
growing industries in the United States, with approximately 32
million tanners and estimated revenues of more than $1 billion/year
in 1997, growing to $5 billion/year in 2002.2 Between 1986 and 1996, there was
a three-fold increase in the percentage of Americans who used
tanning booths.3 Women and
young people (16-34 years old) are significantly more likely to use
such devices and to use them regularly.4 Tanners vary widely in their use
of tanning beds, but 10% or more have over 20 hours of exposure per
Studies into the reasons behind excessive tanning have focused
primarily on psychosocial factors such as appearance motivation,
personal beliefs, and perceptions of risk. It seems self-evident
that the main reason people tan is to have darker skin. Yet while
some will tan a few times to get a tan, others tan far more often
than needed to maintain one, to the point that it seems like an
"addiction" for some frequent tanners.
To see if tanning does have addictive qualities, Wartham et al.
gave 145 tanners a questionnaire testing DSM-IV-TR (Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision) addiction criteria and a version of the CAGE (a brief
alcoholism questionnaire) modified to evaluate tanning
tanners (53%) exhibited addictive behaviors based on DSM-IV-TR
criteria, and 26 tanners (18%) exhibited addictive behaviors based
on both DSM-IV-TR and CAGE criteria. These data suggest that
frequent tanning has features similar to other addictive
These findings were supported by more recent work by Zeller et
al., who conducted telephone interviews with more than 1,000
adolescents.6 They identified
"difficulty in quitting" indoor tanning in 267 adolescents (20.9%
of total) who tanned indoors more than once in the previous year.
Difficulty in quitting was more likely with younger age at
initiation (age 13 years or younger vs. ages 16-17; odds ratio =
4.3, 95% confidence interval 1.3-14.7) and higher frequency of use
(P=0.009), even after accounting for positive or negative
consequences of indoor tanning and other demographics. Those with
difficulty in quitting were more likely to report that tanning was
relaxing. The investigators concluded that the findings were
consistent with other potentially addictive behaviors taken up
Is tanning behavior simply an excessive behavior driven by
social perceptions about tanning, or might there be a physiologic
effect of UV exposure that drives tanning behavior? Reports that
tanning is relaxing suggest that physical effects are possible. To
explore this, our group performed a blinded, placebo-controlled
trial of UV vs. non-UV stimuli in 14 frequent tanners.7 The frequent tanners were tanned
in otherwise identical UV and non-UV tanning beds on Monday and
Wednesday (so that if one bed tanned them, they wouldn't know which
it was). On Friday, they were given a choice of beds. Almost
invariably, they chose additional tanning from the UV bed.7 They reported that the UV bed was
more relaxing than the non-UV bed.
It appears that UV does provide a physiologic stimulus that is
perceived positively by frequent tanners. What could account for
this? Some studies, though not all, suggest that UV induces
production of cutaneous endorphins.8-12 Might UV-induced endorphins
account for a physiologic drive toward UV exposure in frequent
To test this, our group repeated the UV/non-UV choice study in 3
subjects given the opioid blocker naltrexone.13 In one subject, the preference
for UV was diminished. In the other 2 subjects, however, an
unexpected event occurred: Subjects developed nausea and
jitteriness. These are symptoms associated with withdrawal in
chronic narcotic addicts given a narcotic blocker. Could frequent
tanners be addicted to UV-induced opioids or were the observed
symptoms simply a non-specific effect of naltrexone?
To explore this further, we performed a blinded,
placebo-controlled, escalating-dose trial of naltrexone in 8
frequent tanners and 8 controls.14 For controls, we chose people
who had tanned in the past but who were not regular tanners (we did
not want to expose tanning-naïve individuals to indoor tanning).
Subjects were first given 5 mg of naltrexone or placebo at the
first two sessions, 15 mg of naltrexone or placebo at the second
two sessions, and 25 mg of naltrexone or placebo at the third two
None of the infrequent tanners developed nausea or jitteriness
with placebo or with naltrexone. None of the frequent tanners
developed these symptoms with the placebo. Four of the 8 frequent
tanners did develop symptoms at the 15 mg naltrexone dose; 2 of the
4 with symptoms had symptoms so severe as to require withdrawal
from the study.
These controlled trials support a physiologic effect of UV
driving tanning behavior in frequent tanners. The naltrexone
studies suggest that, at some level, opioids are involved in this
physiologic pathway. Is tanning addictive? It certainly appears to
be so for a subset of frequent tanners. Dermatologists need to
remind patients of the harmful effects of UV exposure.
- 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
- 32 Million New Tanners: Imagine What That Could Do for Your
Salon. Tanning Trends.
- The $1,000,000 Industry. Looking
- Rhainds M, De Guire L, Claveau J. A population-based survey on
the use of artificial tanning devices in the Province of Quebec,
Canada. J Am Acad Dermatol.
- Warthan MM, Uchida T, Wagner RF Jr. UV light tanning as a type
of substance-related disorder. Arch
- Zeller S, Lazovich D, Forster J, et al. Do adolescent indoor
tanners exhibit dependency? J Am
Acad Dermatol. 2006;54(4):589-96.
- Feldman SR, Liguori A, Kucenic M, et al. Ultraviolet exposure
is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol.
- Gambichler T, Bader A, Vojvodic M, et al. Plasma levels of
opioid peptides after sunbed exposures. Br J Dermatol.
- Wintzen M, Ostijn DM, Polderman MC, et al. Total body exposure
to ultraviolet radiation does not influence plasma levels of
immunoreactive beta-endorphin in man. Photodermatol Photoimmunol
- Wintzen M, de Winter S, Out-Luiting JJ, van Duinen SG, Vermeer
BJ. Presence of immunoreactive beta-endorphin in human skin. Exp Dermatol.
- Wintzen M, Yaar M, Burbach JP, et al. Proopiomelanocortin gene
product regulation in keratinocytes. J Invest Dermatol.
- Kaur M, Liguori A, Fleischer AB Jr, et al. Plasma
beta-endorphin levels in frequent and infrequent tanners before and
after ultraviolet and non-ultraviolet stimuli. J Am Acad Dermatol.
- Kaur M, Liguori A, Fleischer AB Jr, et al. Side effects of
naltrexone observed in frequent tanners: could frequent tanners
have ultraviolet-induced high opioid levels? J Am Acad Dermatol.
- Kaur M, Liguori A, Lang W, et al. Induction of withdrawal-like
symptoms in a small randomized, controlled trial of opioid blockade
in frequent tanners. J Am Acad