Should Tanning Be Considered Addictive?

Despite well-documented health risks, indoor tanning is still popular in the United States: More than 10 million Americans use tanning beds every year. Of those people, most go more than once, according to Jared Stapleton, a public health researcher at Rutgers University. Some of them—up to 5 percent among college students, the most-studied demographic—develop a compulsion to tan. Colloquially referred to as “tanorexia,” or even “tanning addiction,” the behavior displays many of the markers of a true addiction. Some experts in the psychiatric and public health community even argue that it is one, regardless of the fact that it’s not yet classified as such by the American Psychiatric Association.

Currently, only one behavioral addiction—gambling disorder—is recognized by the APA , and that behavior was only recognized a few years ago in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, aka DSM-5. But the addition of a behavioral addiction to the DSM points to a change in the APA’s understanding of addiction, Stapleton says, one that may result in other behavioral addictions such as tanning being added to future editions. Unlike gambling, he says, tanning “is a relatively new public health issue,” and one that doesn’t affect as many people as, say, smoking, another cancer-causing behavior. For that reason, he says, behaviors like smoking receive far more research funding.

As for the DSM, problematic gambling was an obvious place to start compared to tanning dependency, Stapleton says. "Problematic gamblers are going to have bigger consequences. They may gamble away their life savings [and] go into bankruptcy." Behavioral addictions such as tanning have fewer public-facing consequences and are more difficult to track and study, he says. But for frequent tanners who wind up with deadly skin cancers such as melanoma—the deadliest form of skin cancer—the consequences can be fatal.

Counting those who survive, indoor tanning is to blame for more than 260,000 cases of skin cancer every year and more than $300 million per year in medical bills in the US alone. These are just two of the reasons that Stapleton, who authored the Behavioral Addiction Indoor Tanning Screener in 2016, thinks tanning shows the hallmarks of a behavioral addiction like gambling.

For inclusion in the the DSM, however, addictions need to meet eleven specific criteria in four categories: They need to have a physiological mechanism or effect, people need to pursue their habit despite knowing it has negative consequences, they need to be preoccupied with thoughts of the habit, and it needs to be something that has external consequences—such as bankruptcy for a gambling addict. “In my book, tanning addiction fits all of them,” says Petros Levounis, chair of the department of psychiatry at Rutgers New Jersey Medical School and author of 11 books on addiction.

What it will take is more research and a better understanding of how to frame tanning addiction: how it can be understood, what kinds of people are affected by it, and how it can be treated. That’s challenging when the psychiatric community doesn’t yet formally recognize tanning as an addiction. The evidence is there, but it isn’t complete—however, that might be changing.

Carolyn Heckman, a cancer researcher at Rutgers who has studied tanning for more than a decade, says the evidence of tanning’s addictive qualities has become more convincing in recent years. Addictions have a physical basis—that is, they do something to our brains that feels good and our brains consequently want more of, so we repeat the behavior.

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It may sound surprising that people can develop an addiction to UV light, but a growing body of evidence suggests that might be what’s happening. The research, which dates back to the early 2000s, looks at the relationship between endorphins—chemicals in the brain that make us feel a natural “high”—and extreme tanning behavior.

In one early study—frequently cited in the literature on tanning dependence—eight people who tanned between 8 and 15 times per month and eight who tanned fewer than 12 times per year, or once a month, were shown to have differing responses to naltrexone, a drug given to people with opioid addiction after they’ve gone through detox. Naltrexone works by blocking opioid receptors in the brain, which means that if someone with an opioid addiction takes the drug before detox, they experience symptoms of withdrawal.

After detox, however, it can help them avoid a relapse. The tanners were all given low doses of naltrexone or a placebo. They then used tanning beds that either emitted UV rays or just appeared to do so, and recorded their preferences afterwards. The frequent tanners picked the UV-ray emitting bed less often when on naltrexone, and even exhibited withdrawal symptoms such as jitters and nausea. “Adverse naltrexone reactions suggest frequent tanners may have chronically elevated endorphin levels,” according to a 2017 review of tanning studies that Stapleton coauthored.

While rates of tanning are falling, Stapleton says the problem isn’t going away. The people who tan most excessively tend to be college-aged, white, and female. Nearly one in three women in this demographic go indoor tanning every year, according to the same 2017 review. But they aren’t the only ones who tan—they’re just the ones who are studied most often, says Matt Mansh, a professor of dermatology at the University of Minnesota.

In his own research on tanning behaviors, for instance, Mansh found that the rate of indoor tanning in gay and bisexual men mirrors that of young white women, but they have not been studied in detail for for indoor tanning or other risky UV exposure behaviors like outdoor tanning and not wearing sunscreen. This suggests the problem of indoor tanning—and by extension, tanning addiction—may be more widespread than existing research has documented.

What interventions and alternatives do exist, however, are often inadequate—or haven’t been properly vetted. “When tanners realize that the behavior might be a problem for them, clinicians [aren’t] well-prepared to help them since we don’t have any interventions that have been well-tested,” Heckman says. “So they may continue to tan and harm their skin well after college age.” There’s also evidence that existing interventions could actually worsen the problem. Mansh and colleagues, for instance, just published a new study that looks at whether sunless tanning—using lotions or spray tans—makes people stop using indoor tanning or engaging in other risky behaviors.

Using national data from a 2015 survey, Mansh found that those who use sunless tanning products—about six percent of adults surveyed—are actually more likely to indoor-tan. Part of the reason for this, he believes, is that tanning salons often offer packages that include both indoor tanning sessions and spray tans, which means that someone who comes in for a spray tan might also try indoor tanning, or that someone trying to spray tan in order to cut down on or stop indoor tanning would struggle to stay away from the beds. So while dermatologists often recommend spray tans to patients who engage in indoor tanning to cut down on their behavior, the evidence suggests it doesn’t necessarily work.

If tanning were labeled an addiction in the DSM, Levounis says, the psychiatric community would be able to provide better care. “We have to dance around the diagnosis,” he says, and discuss other things such as body dysmorphic disorder, obsessive compulsive disorder, and anxiety or mood disorders—all things that tanning has been linked to. If tanning were a DSM-documented addiction, he says, “It would make treatment more honest and more available.” It would also help demonstrate to the public the potential severity of a behavior that’s often laughed off as a personality quirk or vanity gone overboard.

Addiction can resemble a knot—one that ensnares a wide range of behaviors, disorders, and coping mechanisms. For the subgroup of tanners who take things to extremes, the first step toward unravelling that knot could mean acknowledging they have an addiction to begin with, one that has both a physical and psychological component and requires treatment. Until that happens, researchers will continue to work on finding more effective interventions for problem tanners, Heckman says. But until exactly who tans—and why they tan—is better identified, it will remain a challenge to regulate tanning effectively or raise awareness of excessive tanning as a problem, rather than a TLC special.

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