differences between this version and the Version Version the and version this between differences throughcopyediting, the typesetting, pagination and proofreading process, which may leadto This articlehas beenaccepted for publicationundergone and full peer review buthas not been Date: Accepted Received Date:23-Dec-2016 This article is This protectedAll rights byreserved. copyright. 10.1111/jdv.14138 Article Type: Type: Article B Cartmel, PhD Running head: Title: PhD Accepted Scholar Research Mentored a by MPH wassupported PhD, Ferrucci, M. Leah PI). Halaban, National by the funded Cancer Skin in SPORE Sources: Funding Email: NewHaven, CT 06510 Fax: 55ChurchSt, Suite 801 Tel: [email protected] Yale School ofPublic Health 203-764-9434 203-764-9083 Brenda Corresponding Author: Cartmel, PhD Article 5. 4. 3. 2. 1. 1 ; P Spain, MPH ; PSpain,

Predictors of Tanning Dependence in Dependence ofTanning Predictors UniversityMassachusetts of Medical School Administration. views of the authors anddo not necessarily reflect those of the Food and Drug Administration. The opinions andconclusions expressedthis article in aresolely the affiliation: Center FoodCurrent Safe for Center Cancer Yale Yale School ofMedicine Yale School ofPublic Health Original Article 1,3 10-Jan-2017 Predictors of TanningDependence ; AE Bale, MD AE Bale, ; This studywas supportedin part by NIH/NCI: R21 CA155952 and the Yale 1 ; DJ Leffell, MD Leffell, ; DJ

2,3 ; ST Mayne, PhD ; STMayne, 2,3 ; S Pagoto, PhD S Pagoto, ; White Non-Hispanic Females and Males CancerInstitutegrant number P50 CA121974(R. ty and Applied Nutrition, Food and Nutrition, tyand Drug Applied of Record. Please cite this article as doi: asdoi: article this cite Please Record. of 1,3,4 ; JE Gelernter, MD, PhD 5 ; LM Ferrucci, PhD 1,3

2 ; AT DeWan, ; AT DeWan, exercise ‘’, and depression). Information Information depression). and ‘addiction’, exercise other behaviors(alcoholdependence, nicotinedependence, seasonal affective disorder(SAD), and TD ascertain to survey online an completed carcinoma cell basal early-onset of study control Methods: Non-Hispanics of European-ancestrywho had previously participatedin a case- (TD). dependence tanning of predictors identify To Objective: fewstudieshave investigated predictors of tanning dependence (TD). dependenceultraviolet on (UV) knowna light, ca of symptoms exhibit may individuals some that suggests evidence Growing Background: ABSTRACT InterestConflicts of Disclosure: Society. Grantin Appliedand Clinical Research,MRSG-13-016-01-CPPB from the American Cancer This article is This protectedAll rights byreserved. copyright. (OR 6.55: 95% CI 3.19-13.42), SAD(OR 2.77; 95% CI 1.26-6.09)exercise and ‘addiction’(OR (OR) 6.93;Confidence 95% Intervals (95% (3.36-14.27)) CI) men. than dependence mode the multivariate In as‘TD’. classified were Results: In total, 499 individuals completed survey online the (81.9%participationrate), 24.4% questionnaires. classifiedas‘TD’ if positive onbothquestionnaires and not TDif negative on both Revision(mDSM- Text Fourth Edition, Disorders, Guilty, Eye-opener(mCAGE) andmodified the Diagnostic and Statistical Manual Mental of were previously enrolled. Lifetime TD was assessed using the modified Cut down, Annoyed, history of sunbathingindoor and tanning,wasobtained from ain which studythe participants Accepted5.47; 95%CI 1.15-26.06) were significant all predictors for TD. Article None Declared. Declared. None l, womenweremore to be likelyTD (odds ratio rcinogen, in rcinogen, the ofcontext tanning; however, on host factors,as such IV-TR) questionnaires. Participants were skin and eye color and and eye color skin and This has come to be known as tanning dependence (TD) in the literature. UV without light, suggesting that UV light may ha observed insubjectsusing when tanning a UV bed, butwhen not using a shamtanning bed was reward of experience the with associated regions brain the in activity increased addition, In [11]. light UV and relaxation) well-being, effect, (positive mood between association similarly designed double-blindstudyfibromyalgia in patients founda significantpositive 95% of participants, indicating tanning might have UV-emittin for observed preference aphysiologic that tanners frequent study in a double-blind includes dependence UV for evidence Supportive cancer. as skin such consequences, adverse known or experienced despite tan to UV tanning,analogous with [9] where, for example, individuals continue appearance; however, recent evidence suggests tanning beds. The motivation to tan has typically been thought to be preference for a tanned individualscontinue toexpose themselvesto UVvia exposure sun tothe anduse indoor of United States [2, 3] and globally [4-8]. Despite knowledge of the harmful effects of UV, rates the in increasing incidence with --cancers [1] cancer and skin melanoma non Icarcinogen aClass is light (UV) INTRODUCTION KEYWORDS be designed. Conclusion: Increased knowledge of those at risk This article is This protectedAll rights byreserved. copyright. Accepted Article Tanning dependence; Ultraviolet light; Skin Cancer. light; Cancer. Skin dependence; Ultraviolet Tanning and the primary environmental risk factor for for riskfactor environmental primary the and that some individuals may become dependent on for TD will allow appropriate interventions to to interventions appropriate allow will TD for g tanning beds compared to non-UV lightto non-UV in gcompared tanning beds reinforcing reinforcing properties [10]. Results from a ve centrally rewardingproperties [12, 13]. an online survey assessing TD and other behaviors. The survey was conducted case- after the conducted was The survey behaviors. other TDand assessing survey an online a partic subset of recruited we analyses, For these factors. control study, subjectscompleted an in-person structured interview pertaining to skin cancer risk in ageamong individuals under 40 (BCC) carcinoma Theindividualsstudy inthis had participatedcase-controla in studyof early-onset basal cell METHODS largea sample of and women men witha history of volitional exposureto UV light. behaviors and factors associated with TD [18-20]. In this report, weexplore predictors of TD in Revision (mDSM-IV-TR) questionnaires [17]; however,limited research available is on and the modifiedDiagnostic and StatisticalManual of MentalDisorders, Fourth Edition, Text modified for tanning, namelymodified-Cut the TD has beenassessedseveral inpopulations two substance-related with disorderquestionnaires avoidance of withdrawal’ [16]. chronicUVexposure’ and‘this that effect was sufficient guide to operant behavioral choicesto Similarly, work donerodents with shows thatblockade ‘opioid alsoelicitswithdrawal signsafter pl to ascompared tanners frequent in symptoms of , anopioid antagonist, diminished preferencefor UV lightand induced withdrawal opiomelanocortin (POMC)gene promoter[14].randomizedA study showedadministration that beta-endorphin and adrenocorticotrophic hormone (ACTH), via stimulation of the pro- exposure. Briefly,UV light induces p53 protein expression, which results increased in levels of A proposed TDis for mechanismthe production beta-endorphinof responsein to UV light This article is This protectedAll rights byreserved. copyright. Accepted Article

down, Annoyed, Guilty,Eye-opener (mCAGE) acebo, implicating implicating an acebo, opiodergic pathway [15]. ipants fromthecase-controlipants studycomplete to Connecticut [21, As 22]. part case-of the reduce overestimation of TD [24]. to used scaleswas different two of combination a on based TD of classification restrictive This were they TD if not as classified were participants onboth the scalesusing positively asTD identified were they if TD as classified were Participants scale. that for 18] [17, criteria metTD items nine the to responses affirmative more or three with individuals mDSM-IV-TR, For the 23]. 18, TD [17, as classified were scale mCAGE the on questions four the to responses affirmative more or two with Individuals analogously). designed but DSM, of the ofany version a not part (i.e. 23] [17, questionnaire mDSM-IV-TR-analogous 23] the and [17, mCAGE TD: the lifetime questions. The remaining 499 individualscompleted two established TDscalesassessing or used a tanning(i.e. bed volitionally tanned), Of the 548 individualswhoaccessed theonline survey, TD 49 reported never having sunbathed Assessment and Classification of Lifetime TD rate). response (81.9% TD survey the completed haveinternetaccess notwant orcomplete did to the surveyonline.548ofA total subjects not did who subjects of number small the to sent was survey paper A by Qualtrics©. hosted Wethese studies. approached subjects by ma controls),atotal of (87.9%) 669 subjects indicateda willingness tobe recontacted foradditional eligiblefor thisonline survey. remaining Ofthe individuals 761 (374 BCC cases and387 European-ancestrysubjects the incase-control study, who were six aged under18 werenot control studyby which some time subjects were agedover 40.the Of original 767 non-Hispanic This article is This protectedAll rights byreserved. copyright. Accepted Article il, requesting they complete an onlinesurvey an complete they requesting il, so were not eligible to complete theTD tocomplete eligible were not so identifiedboth as notTD scales on 255). (n = criteria described above (n = 122). Similarly, Similarly, 122). (n= above described criteria stimulants, , inhalants, sedatives or sleeping pills, hallucinogens, street street hallucinogens, pills, sleeping or sedatives inhalants, methamphetamine, stimulants, prescription cocaine, cannabis, assessed: was drugs following the of use Ever use: Drug [31]. ‘addiction’ exercise for ‘addiction’ inventory (which, like item exercise six the on above or 24 of A score life” [30]. professional and social her or his in to as health well as consequences negative experiences and dependence, exhibits compulsively, habitually exercising individual loses controloroverherhis exercise andacts habits Exercise‘addiction’: hasbeen This described“aas morbid patternof behavior inwhich the greater (significant depressivesymptomatology). D) [29].Participants were dichotomized as less(no 16 than depressivesymptomatology) oror 16 Depression was assessed using the Center for Ep abuse’‘Symptomsor alcohol of abuse’ ‘Symptoms or of alcoholdependence’ [28]. alcohol of symptoms ‘No as classified were Individuals Version. Lifetime (MINI) Interview completeto questions fromthealcohol section of MiniInternational the Neuropsychiatric drinks withinathree-hour period onthreemore or occasions during their lifetimes were directed alcoholic more or three consumed had who Participants abuse/dependence: alcohol of Symptoms Respondents werecategorized either as low dependence (0-5) or high dependence (6-10) [27]. instructed to‘Thinkabout the period lastinga month more or you when were smokingmost.’the Fagerstrom the to complete asked were lifetime NicotineDependence: Participantswho reported smoking more thancigarettes100 intheir [25, (SPAQ) 26]. Assessment Questionnaire Pattern Seasonal the using assessed were SAD symptoms (SAD): Disorder Affective Seasonal Assessment of Behavior and Lifestyle Factors This article is This protectedAll rights byreserved. copyright. Accepted Article TD, isnota standardDSM diagnosis)wasconsidered at risk Test for Dependence (FTND) and were were and (FTND) Dependence Nicotine for Test idemiological Studies Depression Scale Scale (CES- Studies Depression idemiological consent. Committee(Protocol #0612002107, Approved: 02/02/2007).Subjects provided writteninformed Human and Subjects Institutional Review Board byUniversity Yale study the approved was Our Ethics NC). Inc., Cary, (SAS Institute software significant at the0.05inunivariate level analyses. were statistically models that were those themultivariate building in were evaluated model for predictors of TD retaining the variables witha p-value< 0.05. using se built models were backward Multivariate wereused toassess predictorsofTD using ‘not tanningdependent’ as comparison the group. models Logisticregression of variance. analysis test,and Fisher’s exact test, the chi-squared Univariate associations betweenandother TD behaviors andfactors host were evaluated using Statistical Analysis alcohol consumption were available from the case-control study structured interview [22]. color,etc.), lifetime sessions, sunburns from outdoor exposure, andlifetime Skin CancerFactors: Risk Data on sociodemogra Marijuana’. than other drug of ‘Use or use only’ ‘Marijuana use,’ ‘Never into categorized was Use . prescription and opioids, This article is This protectedAll rights byreserved. copyright. Accepted Article

phics, host characteristics (e.g. eye color, skin skin color, eye (e.g. characteristics host phics, lection toconstruct themostparsimonious

Data were analyzed using SAS 9.4 9.4 SAS using analyzed were Data The variables which which variables The sessions ( ‘addiction’ and female sex. includingahistory of symptoms alcohol of addiction, SAD, a historyrisk of exercise of duringtheir foundwe lifetime, that 24.5%had ‘T In study our of non-Hispanic young white women and menwho reported volitional tanning DISCUSSION 4). (Table TD not to compared ‘TD’ having with associated significantly were 26.06) 6.55; 95%CI 3.19-13.42),and history ofexerciseof risk ‘addiction’ (OR5.47; 95%CI 1.15- CI) 3.36-14.27), 2.77;SAD 95% (OR CI 1.26-6.09),a history of symptoms of alcohol abuse(OR multivariateIn the regression model, (oddsratio sex (OR) 6.93;95% Confidence interval (95% TD(Table 3). with were associated (p=0.01) addition exercise history of symptomsof alcohol addiction(p<0.0 reaction‘Very as brown,deeply tanned’being more likelybe to ‘TD’ (p=0.005) (Table A 2). prolonged sun exposure was significantly associated with TD, with those who reported their who were notTD ( Those who were ‘TD’ reportedengaging more inthe lifetime indoortanning sessionsthan those on onlyone scale (n=122)were excludedfrom theanalysis. were males) of females and69.3% of (45.1% participants 225 and scales) both on TD for (positive ‘TD’ having as classified were IV-TRis shownTablein 1.(24.5%) 122 participants (29.1%of females and 10.4% of males) mDSM- the and mCAGE the asassessed by TD of years. concordance The was38.5+4.8 survey the of at completion age average the and (75%), wasfemale participants 499 the of majority The RESULTS This article is This protectedAll rights byreserved. copyright. Accepted Article 706303; vs. 424 vs. 46;424 vs. p<0.0001) (Table In 2). theunivariate skin reactionanalysis, with p<0.0001)(Table A similar 2). pattern was seen for sunbathing classified as not tanning dependent. Those who were positive whowere tanningThose as not dependent. classified 01), SAD (p=0.001) and a history of risk of D’. We identified several predictors of TD, predictorsofTD, Weseveral identified D’. female university students, 24.5%whom of were tanningdependent, SADwassignificantlynot college studentswho tanned indoormore frequently [37].However, arecent in study 306 of SAD and symptomsSAD of have previously been reported morebe to commonfemale in required to gain a better understanding of this relationship. However, [36]. factor causative common a as hypothesized temperament [35],further supporting arole ofanappearancemotivation driven to tan, with neurotic males females and both in indoor tanning and behaviors control unhealthy weight between link a suggests adolescents of samples representative nationally a in research Recent [33][34]. behaviors tanning to related has been appearance one’s for concern the and appearance, individualswhoare at risk exercise for ‘addiction’ maybe driven exercise’s by impacts on positive association between moderateex anaerobic ‘addiction’, respective to those who were not TD. Heckman et al. [32] reported a borderline exercise of risk of a history have to as likely times were three TD were who those that ofTD, finding as a predictor ‘addiction’ exercise the to first examine are we knowledge, our To or dependencecompared tothose whowere not tanning dependent[19]. abuse alcohol of symptoms have to morelikely times three were asTD classified were who those researchers [19].For example, in groupa of over 300 female college students aged 18-25years, symptomsof andalcohol are use inconcordance withthose of other tanners [18]. However, our findings regarding thepositive association between TD and indoor active recruited tanning otherstudiesonlyvolitional population[17], while inthestudy assess TD and differing eligibility study criteria.Forexample, assess didnot some studies hampered the by of usediffering definitionsofTD are studies across comparisons TD, of predictors examined have studies several Though This article is This protectedAll rights byreserved. copyright. Accepted Article , , a result of the use instruments ofdifferent to ercise (p=0.07) Itand TD. is possible that further research is research further TD, and so TD may be susceptible to poor recall. However, the percentages of our population population our of percentages the However, recall. poor to susceptible may be TD so and TD, subjectslifetime (asking TD thinkto back over thanlifetime), assessmentrather of their current telephoneOurcollection. data studyalso has some potential weaknesses including assessmentof study were online, may which besusceptible lesssocial desirability to biasin-person than or in thisgroup. theassessme misclassification All assess to to designed the TDleading complete questionnaires to accurately unable tanning,volitional those whohave soinclude hadvolitionally not tanned.Previous studieshave not restricted enrollment based onhistory of who individuals of exclusion and size sample alarge including strengths, several has study Our to males. compared ‘TD’ have to 7timesalmost more likely indoortanners recruitedfrom community the [32]. In study, ourwe found that females were significant 1.37females odds ofbeing tanning dependentcompared males andgroup toa in of anon- reported [32] et al Heckman TD. of predictor asa sex evaluated have studies Few [23]. community from the recruited grouptanners indoor drugs)in a of illicit and alcohol nicotine, (e.g. disorders addictive other with association no was there however, [18]; in use marijuana study, our in TD with associated depressionnot was associated with TDWhile inour population. wasdrug also use not association between dependence nicotine andin reports As TD. fromstudies other[18, 19], generallySmoking has been not associated with TD [18, 19, 23]. Similarly, we foundno as “self-medication.” hypothesize that lightexposure be might improve to sought depressiveand symptoms be viewed thosein who had‘TD’compared those to who were nottanning dependent. In these subjects, we frequent more times three almost was SAD that found we contrast, In [19]. TD with associated This article is This protectedAll rights byreserved. copyright. Accepted Article never sought out UV exposure and are likely likely are and exposure sought UV out never nts for TD and other addictive behaviors in our in behaviors addictive for TD and other nts the prior 30 days has been associated with TD with TD associated days hasbeen the 30prior UV in exposure. a reduction toachieve may to be addressed need conditions SAD suggeststhat assessment these of conditions TD, between associations work Our showing CONCLUSION particularly as unsupervised indoor tanning research; further warrants TD and ‘addiction’ exercise of risk between association the on may reduce UV exposure in individuals with SAD who are tanning dependent. Also, our finding SAD thatdoexposure notinvolve UV to light, such as light therapy deliveredviaa light box, for treatments risk of encouraging an sinceTD, SADwaswith associated For example, increased useful inmodifyingcancerskin prevention messagesandinterventions forthese subgroups [40]. reduce indoor tanning and sunbathing behaviors.The predictors of TDidentified we may be Individuals[39]. whoaretanning dependentmay require additionaltargeted interventions to US [38, 39] are encouraging, anestimated 9.7million adults in the US continue to indoor tan andadolescents inthe tanning adults by of thedeclining useofindoor Althoughreports recent case status. by BCC difference minimize any to attitudes and exposure lifetime about think to individuals asked generalizability ofthe study. However, allthe tanningbehaviorquestions and the scales TD the the thus to responses TD scales, limiting mayaffected have diagnosis cancer additional potential limitationis the inclusion patients of diagnosed BCC, withthisas skin separatelyare similar verythoseto reported for other studies of volitional tanners. who metcriteria the TD for based onmCAGE the (29.1%) andmDSM-IV-TR (44.3%) This article is This protectedAll rights byreserved. copyright. Accepted Article

facilities are available in many are gyms available in facilities some is important in excessive tanners, as these these astanners, is important inexcessive addictions including alcohol addiction, alcohol including An and Dermatol. 2011;65;S17-25 e11-13. J,Kim al. RecentJ, et trends M, P, Barnholtz-Sloan Patel SS, Cherala Jemal Saraiya A, cutaneousin melanomaincidence and death ratesin the United States,1992-2006. J Am Acad [7] Doherty VR, BrewsterDH, JensenS,Gorm socioeconomic position in Scotland, 1978-2004. Br J Cancer. 2010;102; 1661-1664. [6] 24-30. and prevalence Incidence, T. Nijsten JW, HA, Coebergh SC,deVries Neumann E, Flohil in basal cellcarcinoma primary of future trends [5] Cancer. 2007;121; 2105-2108. of incidence in Trends R. Hubbard A, Meal C, J, Smith F,Leonardi-Bee Bath-Hextall Intcare J study.primary database Additional aUK evidencecarcinoma. from cell skin basal [4] SEER al. et SF, Altekruse DR, Miller J, M, Garshell Krapcho A, Noone N, Howlader Cancer Statistics Review, 1975-2012. National Cancer Institute. Bethesda, MD. 2015. [3] Dermatol. 2015. SR Feldman MA, Weinstock HW, Rogers JAMA 2012. Population, US the in Carcinomas) (Keratinocyte Cancer Skin Nonmelanoma [2] V, F, of Areview et al. Bouvard B, K,Grosse El Y,Secretan Ghissassi R,Straif Baan human carcinogens--part D: radiation. Lancet Oncol. 2009;10; 751-752. [1] REFERENCES timethis their in participate study. to ACKNOWLEDGEMENTS: ACKNOWLEDGEMENTS: Leffell, Mayne, Gelernter, Cartmel, Bale, funding; Obtained Cartmel analysis: Statistical andMr. Spain. Pagoto Mayne, Leffell, Gelernter, revision of theCritical manuscript for importan Leffell,Mayne, Pagoto and Spain. Draftingmanuscript: of the Drs. CartmelandFerrucci. Gelernter, Ferrucci, DeWan, Bale, Cartmel, interpretationofdata: and analysis, Acquisition, Leffell, Mayne, Pagoto. Gelernter, conceptFerrucci, and Cartmel, Drs. Bale, design: Study analysis. data the of accuracy the and data the of integrity the for responsibility take CONTRIBUTIONS: AUTHOR This article is This protectedAll rights byreserved. copyright. Accepted Article We are indebted to all the partic the all to indebted We are Dr. Cartmel had full access to all of the data in the study and and study the in data the of all accessto full had Cartmel Dr. Pagoto. Study supervision: Cartmel. Study Cartmel. supervision: Pagoto. t intellectual content: Bale, DeWan, Ferrucci, content: Bale,DeWan, t intellectual the Netherlands. the ActaDerm Venereol. 2011;91; , Coldiron BM. Incidence Estimate of Estimate Incidence ColdironBM. , an D. 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TanAssociationsand thin? between attitudes [34] 532-544. appearance-based factors Joelin Hillhousepredicting GC, Thompson JK, sunbathing JacobsenPB, Hillhouse and tanningInvestigating J. salon the use. role of J Behav Med. 2009;32; [33] the of investigation preliminary A KS. Ingersoll DB, Wilson BL, predictors Egleston of CJ, tanning dependence. Heckman American journal of health behavior. 451-464. 2008;32; [32] e30. 2005;39; medicine. sports of journal British practitioners. health for tool easy and a inventory: quick screening addiction exercise A. The A,Terry MD, Szabo Griffiths [31] medicine. 2015;88; 303-308. and ConceptualLimitations inExercise Addiction Research. SzaboThejournal Yale A, of biologyGriffithsand MD, Lade Vega Marcos R, Mervo B, Demetrovics Z.Methodological [30] general the in research scalefor depression a self-report Scale: population. CES-D LS. The Appl Psychol Radloff Meas. 1977;1; 385-401. [29] psychiatry. 1998;59 Suppl 20; 22-33;quiz 34-57. structured diagnostic psychiatric interviewforDSM-IV ICD-10. and TheJournal of clinical ofa and thedevelopment validation Interview (M.I.N.I.): International Neuropsychiatric Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, JanavsWeiller J, E, et al. The Mini- [28] of smokers. Tob Control.1996;5; 52-56. smoking prevalence versus dependence Nicotine FagerstromKO, KunzeM, Schoberberger R, Breslau N, Hughes JR, Hurt RD, et al. [27] affective P,Singh G,Kaur disorders RP, et in P,Sharan Kulhara al. Seasonality N, A, Avasthi Gupta using SPAQ. Indian J Psychiatry. 2003;45; 166-173. [26] This article is This protectedAll rights byreserved. copyright. Accepted Article havioral pediatrics JDBP. : 2014;35;165-171. Audience SegmentationAudience in Campaigns. J Health 2009-2013. JAMA Dermatol.2015;151; 448- Hartman AM. Recent Changes in the Prevalence Prevalence the in Changes AM. Recent Hartman : comparisons among countries and categories categories and countries among comparisons : mDSM-IV-TR and mCAGE the using TD of Assessment 1. Table This article is This protectedAll rights byreserved. copyright.

Accepted 354 (69.9) 255 (51.1) Article 99 (19.8) Not Tanning Dependent ann eedn 12(45 2 46 145 (29.1) 23 (4.6) 122 (24.5) TanningDependent mCAGE mCAGE Total 221 (44.3) 278 (55.7) 499 ann eedn Not TanningDependent Tanning Dependent mDSM-IV-TR

N (%) Total

Table 2. Host Factors and Tanning Frequency by TD (N=377) TD by Frequency Tanning and Factors Host 2. Table This article is This protectedAll rights byreserved. copyright.

Females 169 (66.3) 109 (89.3) <0.0001 <0.0001 (89.3) 109 0.53 39.0(4.3) (66.3) 169 38.6(5.1) Education: Females Age at survey Not TD Accepted <0.0001 706 (467) <0.0001 424 (795) 303 (339) 46 (130) Lifetime Sunbathing sessions Lifetime Indoor tanning sessions 0.11 (58.2) 71 exposure: summersun first with reaction Skin (49.4) 126 exposure: sun prolonged with reaction Skin Fair Very Fair Olive Skin color: Carcinoma Cell Basal Prior >30 Article 25-<30 <25 BMI: 2. 1. > Some graduate school school graduate Some > College/College Grad HStraining Post 9-12 Mildly & burnt some tanning/no sunburn Painful sunburn followed by peeling Severe sunburn no suntan Mildly tendency/freckled peeling tanned tanned Moderately Very brown, deeply tanned

analysis, the Fishers exact test and analysis of variance. variance. of analysis testand exact Fishers the analysis, Differences betweengroupsthe (Not TD andTD) were assessed using Chi-squared May not sum to total due tomissingto totaldue sum values notMay th Grade Grade

N(%) or Mean Mean N(%) or 110 (43.1) (43.1) 110 125 (49.0) (49.0) 125 (57.6) 147 143 (56.1) (56.1) 143 121 (47.6) (47.6) 121 (48.8) 124 99(38.8) 73 (28.6) 52 (20.4) 31 (12.2) 82 (32.2) 26 (10.2) 45 (16.6) 67 (26.3) (N=255) 20 (7.8) 9 (3.5) (SD)

2 1 N(%) or Mean Mean N(%) or 33 (27.0) 47 (38.5) 34 (27.9) 63 (51.6) 50 (41.0) 31 (25.6) 66 (54.1) 25 (20.5) 32 (26.2) 79 (64.7) 17 (13.9) 82 (67.2) (N=122) 11 (9.0) 23(18.8 8 (6.5) 9 (7.4) (SD) TD

2

P-value 0.0005 0.44 0.44 0.01 0.01 0.41 0.12 0.12 missing due values May to tototal 2. sum not test. Fishers exact the and analysis squared 1.Differences between thegroups (Not TD and Symptoms of TD) were assessed using Chi- only) (current or past smokers Nicotine addiction Dependence Abuse No addiction: Alcohol of History Addiction ofExercise History History ofDepression Symptoms ofSAD Poly drug use only Marijuana use Never Illicit drug use: Table3. Behaviors (n=377) TD by This article is This protectedAll rights byreserved. copyright. Accepted Article Not TD 159 (62.3) (62.3) 159 63 (24.7) 80 (34.2) 56 (23.4) 98 (41.9) 31 (12.2) 65 (25.5) (N=255) (N=255) 3 (1.18) 14 (5.5) 9 (9.0) 9 (9.0) N(%) N(%)

1

2

50 (45.4) 25 (22.7) 35 (31.8) 1(36 0.07 0.0002 41 (33.6) 21 (17.8) 32 (26.2) 43 (35.2) 47 (38.5) (N=122) (N=122) 9 (17.3) (17.3) 9 57 0.013 7 (5.7) N(%) N(%) TD

2

P-value P-value 0.0001 0.10 0.26 TD Not vs. TD Yes No N Riskof Exercise ‘Addiction’ Abuse Dependence abuse or dependence No Alcohol Yes No SAD Female Male Sex of model predictors 4: Table ofTD Multivariate This article is This protectedAll rights byreserved. copyright. Accepted Article 7/3 115/222 32/31 43/65 47/159 41/63 81/162 109/169 13/86 5.47 (1.15-26.06) (1.15-26.06) 5.47 1.0 (1.81-5.51) 3.16 (3.19-13.42) 6.55 1.0 (1.26-6.09) 2.77 1.0 (3.36-14.27) 6.93 1.0 OR (95% CI) CI) (95% OR