Consider Tanning Motivations and Counsel AccordinglyTANNING, SKIN CANCER, SEASONAL AFFECTIVE DISORDER

UV exposure is an avoidable cause of skin cancer. Despite evidence that UV exposure increases skin cancer risk, intentional suntanning and indoor tanning are prevalent among many young adults and adolescents.¹ It is widely accepted that these practices persist largely due to prevailing sociocultural values and the perceived attractiveness of tanned skin.² Additional motivations for tanning are increased confidence in appearance and the feeling of attractiveness of tanners, socialization with friends, and feeling of relaxation experienced both during and after a tanning session. Furthermore, recent studies point to motivations related to depression, manifested as seasonal affective disorder, and dependence or addiction factors.³ With administration of naltrexone, an opioid antagonist, frequent tanners had withdrawal symptoms, thus supporting a physiological hypothesis.³ The physiological basis of pathological tanning has been supported by studies demonstrating that UV induction of pigment secretes α-melanocyte-stimulating hormone (a cleavage product of the prohormone peptide proopiomelanocortin; POMC), and cleavage of POMC yields β-endorphin, an endogenous opioid that can induce analgesia and euphoria.⁴

In the May issue of the Archives of Dermatology, Hillhouse et al⁵ reported the results of a randomized controlled trial of 430 adult female tanners on a college campus. Hillhouse et al⁵ found that an appearance-focused intervention to prevent skin cancer is robust enough to reduce indoor tanning among individuals who exhibit seasonal affective disorder symptoms or pathological tanning motives. Tailored interventions may address individuals' motivations for tanning and their relationship to maladaptive behavior.

When counseling patients, physicians should consider the patient's perspective of the benefit of tanning. Is the patient tanning to look good for an event such as a prom or wedding? Is the patient a regular tanner who tans year-round and uses tanning to improve his or her mood and relieve stress? The event tanner is at one end of a continuum that extends through spontaneous mood tanners to regular tanners.⁶ Physicians can elicit this information by taking a history using open-ended questions, such as “How does having a tan make you feel?” This opens a dialog and allows the physician to frame a harm-reduction message that evolves from the patient's responses.

For the event tanner interested in his or her appearance, a suggestion by the physician to consider substituting sunless tanning with a self-applied lotion or a spray-mist tan for UV tanning may be seen by the patient as a worthwhile investment to look good and boost self-confidence. The patient may also be receptive to using sun protection to prevent early aging of the skin; thus, for the appearance-motivated tanner, prevention of wrinkles enables harm-reduction behavior. Regular tanners, who discuss how tanning makes them feel relaxed, may respond to suggestions for other ways to relieve stress such as regular exercise and relaxation methods such as yoga.

Parents should be counseled because they serve as role models and gatekeepers of tanning behavior in their children and adolescents. Because state regulation of access to indoor tanning often requires parental consent for minors, the gatekeeper role of parents is relevant. Parental knowledge about the risks of tanning and attitudes and beliefs toward tanning will shape their decision to allow or disallow their children to tan indoors, underscoring the concomitant need for education efforts targeting parental knowledge of indoor tanning.

Physicians also can advocate for the health of patients at the local community level by encouraging limiting access to indoor tanning for those individuals younger than 18 years, by enforcement in the 32 states that regulate tanning facility use by minors,⁷ and by enforcement of the federal excise tax on indoor tanning for nonmedical use.⁸ Tanning packages are offered for a relatively low flat monthly fee so if the unlimited monthly use of indoor tanning is abolished, taxation of single sessions may become an effective deterrent to indoor tanning. The 10% excise tax goes into effect on July 1, 2010, and is intended as a measure to promote melanoma prevention.⁹ While the intention of the law is to have the increased cost serve as a deterrent to indoor tanning, the owners of tanning establishments have stated that they will pay the tax rather than pass the tax onto the customer. The law does allow the tax to be paid by the person who provides the service in the event that the tax is not collected at the time the service is provided.

The federal excise tax uses a strategy that was successful with tobacco control. Tobacco products, like indoor tanning, are associated with serious health risks, place emphasis on social appeal in advertising, and are used by adolescents. Youth, perhaps because of their lower incomes, are particularly cost-sensitive, and tobacco taxation is the single most effective intervention for reducing demand.¹⁰ Taxation only becomes a deterrent to indoor tanning if the cost is borne by the client and the taxation raises the price until the price becomes a barrier. Physicians, as respected members of the community, can work with the chamber of commerce and local government to prohibit purchase of unlimited tanning sessions at low monthly fees. The federal tax on tanning may help reduce the health risks of contracting skin cancer and the future costs of treating skin cancer.

In the United States, the indoor tanning industry is still increasing rapidly, generating more than $5 billion in revenues and attracting more than 30 million patrons per year, with more than 1 million individuals on average using tanning beds each day.¹¹ It will take a continuing concerted effort by physicians to help patients avoid the adverse effects of chronic UV exposure.