In a metaanalysis of more than 7000 cases, it was found that having ever used a tanning bed was associated with an increased risk of melanoma. These authors also reported that the first exposure to sunbeds before 35 years of age was associated with a significantly increased risk of melanoma, and that there was an increased relative risk for squamous cell carcinoma. This is a concern, because in the United States, nearly 30 million people tan indoors yearly, including 2.3 million adolescents. The indoor tanning industry is a multibillion dollar enterprise, despite the fact that many frequent tanners are aware of this malignancy risk. In a study of 100 young adult beachgoers, indoor tanning behavior increased from 1% in 1988 to 27% in 2007. Seventy-seven percent had knowledge that limiting tanning helped prevent melanoma, but this decreased to 67% in 2007, coincident with an increase from 69% to 81% in the attitude that having a tan looks better. The reason for this disconnect between risk knowledge and continued tanning is complicated and multifactorial.

Why do people tan? Dr Brown has reviewed the history of tanning. The French fashion designer Coco Chanel is credited for initially instilling a desire for a deep tan in the early 1920s, when she was photographed on a yacht with a bronze tan and proclaimed that “a golden tan is the index of chic.” In a recent review, it was found that the typical sunbed user is female, between 17 and 30 years of age, and lives an unhealthy lifestyle that includes smoking, frequent alcohol intake, and unhealthy eating habits. These individuals had a lack of knowledge of the risks of ultraviolet (UV) rays, and they experienced positive emotions, relaxation, and support for their behavior by family members and friends. The element of self-esteem and socialization may explain why it has been difficult to change tanning use with knowledge of risk alone. Furthermore, when the relationship between body image and indoor tanning was investigated in a group of 155 young female tanners, it was found that this population viewed their bodies as objects to be looked at and evaluated. Self-objectification was related to body shame, which was in turn related to both intentions to indoor tan and past indoor tanning.

Misperceptions about tanning also contribute to an increase in indoor tanning. Some feel that tanning offers protection against damaging UV rays. There is no such thing as a safe tan, and the sun protection factor (SPF) offered by an acute tan is approximately 2 to 3. In fact, tanning occurs as a response to UV damage to DNA. Artificial UV light sources that are used in tanning salons have predominantly ultraviolet A light (UVA) bulbs, but the proportion of ultraviolet B light (UVB) from artificial light ranges from 0.1% to 5%. Both spectrums have carcinogenic potential, and the amount of UV radiation exposure may be concentrated to up to five times that of natural sunlight. UVB causes characteristic mutations in DNA that disrupt the replication and transcription of DNA. UVA is absorbed by chromophores in the skin, resulting in reactive intermediates, which cause DNA breaks. P53 is a tumor suppressor gene that helps to repair this DNA damage. This can also undergo mutations from UV damage, and loss of function of p53 leads to aberrant cell growth and genesis of cancer. A link between p53 and the tanning response, or UV-induced pathologic hyperpigmentation, was elucidated by Cui et al. In response to UV radiation, melanocytes produce melanin pigment, resulting in hyperpigmentation. Melanin has a protective role in absorption of free radicals induced by UV radiation. α-Melanocyte stimulating hormone (α-MSH) is a propigmentation hormone that is produced and secreted by melanocytes and keratinocytes after UV radiation. The gene encoding α-MSH is proopiomelanocortin (POMC), and is a mulitcomponent precursor for α-MSH, adrenocorticotropic hormone (ACTH), and the opioid peptide, β-endorphin. P53 was found to act as a UV sensor/effector for tanning. It promotes cutaneous pigmentation following UV radiation by direct transcriptional activation of PMOC. A deficiency of p53 was associated with an inability to tan, and most squamous cell carcinomas and many basal cell carcinomas have mutations in p53, further supporting a relationship between tanning and damaging UV effects. Because the normal tanning response depends on the expression of p53, maintenance of a tan would subject one to unnecessary repeated UV-induced DNA damage.

A campaign by the indoor tanning salon industry claiming that tanning makes one feel good and provides vitamin D have also contributed to the cultivation of tanning activities. The recommendations regarding vitamin D requirements have been hotly debated in the literature. The recommendations for vitamin D requirements are evolving, and are not currently well established. The details of vitamin D metabolism and deficiency have been reviewed. Vitamin D3 is the inert precursor that is produced in the skin after UVB exposure, while vitamin D2 is obtained through diet and supplements. Vitamin D plays an important role in maintaining good skeletal bone health. There have been reports suggesting that vitamin D may be associated with a reduced risk of mortality from malignancies such as colon, prostate, and breast cancer, and with diminished cardiovascular disease, and autoimmune disorders such as diabetes, and multiple sclerosis. However, some of these studies have design limitations that fail to establish a definitive cause and effect. Nonetheless, these studies have been used to encourage UV radiation, including indoor tanning or sunlamps to replenish vitamin D. However, the benefits of using artificial UV light instead of oral vitamin D and limited incidental natural light have been challenged and because some of the published vitamin D research has been funded by a foundation which is an offshoot of the Indoor Tanning Association, familiarization with the literature on this topic is encouraged. While UV radiation does result in vitamin D synthesis, it takes very little exposure to accomplish this. In less than 5 minutes at noon in Boston, a fair-skinned person will maximize the vitamin D synthesis, and this production is capped at about 10% to 20% of the original skin concentration after a single UVB exposure. Because UV is responsible for more than a million skin cancers per year in the United States, unless a person has a problem with gastrointestinal absorption, incidental natural suberythemal sun exposure supplemented by oral vitamin D is the preferred approach to maintaining appropriate vitamin D levels.

Addiction to tanning may also contribute to tanning behavior. Studies on this subject have been reviewed. Tanning may be related to an UV light substance-related disorder (SRD), such that repeated tanning leads to behavior similar to that seen in other substance dependence. In some individuals, tanning met Diagnostic and Statistical Manual (DSM) criteria for SRD, and withdrawal symptoms were seen in frequent tanners. The claim that tanning makes one feel happier may therefore have some truth to it. In fact, there is molecular support for this theory, because theoretically the UV radiation–associated increase in p53 expression may lead to increased β-endorphins via stimulation of the POMC promoter.

It is understandable why the campaign by the indoor tanning industry has been so successful in promoting indoor sunbathing. There are more than 50,000 tanning salons in the United States alone, with an average of 1 million people tanning per day, many of who are 16 to 19 years of age, despite educational attempts by the medical community on the carcinogenic hazards of tanning. The World Health Organization has suggested a complete ban on indoor tanning for individuals under 18 years of age, and there are now at least 29 states with legislature regulating tanning salons. Nonetheless, as we learned in this dialogue, these laws are difficult to enforce, and it is clear that the approach to this problem will have to include efforts that focus on education to increase body satisfaction and self-esteem, similar to eating disorders and substance abuse, and to resist cultural and media pressures that continue to encourage and promote tanning.

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