0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Study |

Addiction to Indoor Tanning:  Relation to Anxiety, Depression, and Substance Use FREE

Catherine E. Mosher, PhD; Sharon Danoff-Burg, PhD
[+] Author Affiliations

Author Affiliations: Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Mosher), and Department of Psychology, University at Albany, State University of New York, Albany (Dr Danoff-Burg).


Arch Dermatol. 2010;146(4):412-417. doi:10.1001/archdermatol.2009.385.
Text Size: A A A
Published online

Objective  To assess the prevalence of addiction to indoor tanning among college students and its association with substance use and symptoms of anxiety and depression.

Design  Two written measures, the CAGE (Cut down, Annoyed, Guilty, Eye-opener) Questionnaire, used to screen for alcoholism, and the Diagnostic and Statistical Manual of Mental Disorders(Fourth Edition, Text Revision) (DSM-IV-TR) criteria for substance-related disorders, were modified to evaluate study participants for addiction to indoor tanning. Standardized self-report measures of anxiety, depression, and substance use also were administered.

Setting  A large university (approximately 18 000 students) in the northeastern United States.

Participants  A total of 421 college students were recruited from September through December 2006.

Main Outcome Measures  Self-reported addiction to indoor tanning, substance use, and symptoms of anxiety and depression.

Results  Among 229 study participants who had used indoor tanning facilities, 90 (39.3%) met DSM-IV-TR criteria and 70 (30.6%) met CAGE criteria for addiction to indoor tanning. Students who met DSM-IV-TR and CAGE criteria for addiction to indoor tanning reported greater symptoms of anxiety and greater use of alcohol, marijuana, and other substances than those who did not meet these criteria. Depressive symptoms did not significantly vary by indoor tanning addiction status.

Conclusion  Findings suggest that interventions to reduce skin cancer risk should address the addictive qualities of indoor tanning for a minority of individuals and the relationship of this behavior to other addictions and affective disturbance.

Extensive evidence has linked sunlamp or sun bed exposure to increased risk of melanoma and nonmelanoma skin cancers.13 Despite ongoing efforts to educate the public about the health risks associated with natural and nonsolar UV radiation, recreational tanning continues to increase among young adults.4 In addition to the desire for appearance enhancement, motivations for tanning include relaxation, improved mood, and socialization.57 These reinforcing properties of UV tanning have been conceptualized within an addiction framework.8 That is, repeated exposure to UV light may result in a behavior pattern similar to other types of substance-related disorder (SRD). In support of this hypothesis, a significant proportion (12%-53%) of young adults and beachgoers has met the criteria for having an SRD with respect to UV light tanning behavior.7,9,10 In addition, having an SRD that involves tanning behavior and the use of indoor tanning devices has been positively associated with cigarette smoking among young adults.9,11 However, to our knowledge, in-depth analyses of the reliability and validity of measures of SRDs that involve self-reported tanning behavior have not been conducted. Research also has not specifically focused on SRD with respect to indoor tanning and its relation to other psychopathological conditions. We hypothesized that a minority of college students would meet the criteria for an SRD with respect to indoor tanning and that having this disorder (determined by self-report) would be positively related to anxiety, depression, and substance use.

A total of 421 undergraduates were recruited from the psychology department research participant pool at a state university in the northeastern United States from September through December 2006. All study materials and procedures were approved by the university's institutional review board. After providing written informed consent, study participants anonymously completed questionnaires in groups ranging from 15 to 30 people. Participants reported their demographic information, whether they had ever tanned indoors, and frequency of indoor tanning during the past year.

To assess potential dependence on indoor tanning, we modified 2 measures that are widely used to identify SRDs: the 4-item CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire,12 used for alcoholism screening, and the 7 diagnostic criteria for an SRD as outlined in the Diagnostic and Statistical Manual of Mental Disorders(Fourth Edition, Text Revision) (DSM-IV-TR).13 Versions of these measures were used in prior research to assess addiction to UV light tanning.9,10 In this study, CAGE and DSM-IV-TR criteria referred to indoor tanning behaviors. Following the scoring procedures of Warthan and colleagues,10 2 or more affirmative responses to items on the modified CAGE (mCAGE) and 3 or more affirmative responses to items on the modified DSM-IV-TR (mDSM-IV-TR) were, respectively, classified as indicating a probable SRD that involved indoor tanning. Scoring procedures for 3 questions in the mDSM-IV-TR with multiple parts were as follows: (1) question 1 was counted as affirmative only if both subparts were answered yes; (2) question 5 was counted as affirmative with 2 or 3 positive responses (any response other than none was classified as a positive response to subpart 5a); and (3) question 7 required a response of no to subpart 7c and a response of yes to subparts 7a and/or 7b to be considered an affirmative response. Internal consistencies for the mCAGE and mDSM-IV-TR were .58 and .56, respectively. Deletion of individual items did not significantly alter the α values, which are relatively low but consistent with those found in prior research on SRDs related to tanning behavior9 and most likely reflect the wide range of behaviors assessed by the measures and the brevity of those measures.

Participants completed the Beck Anxiety Inventory14 and the Beck Depression Inventory,15 which are widely used 21-item scales that assess symptoms of anxiety and depression, respectively, during the past week. Internal consistencies for the Beck Anxiety Inventory and the Beck Depression Inventory in the present study were .91 and .87, respectively. In addition, participants completed portions of the Core Alcohol and Drug Survey,16 a validated measure of substance use. Participants reported the number of days they had used 1 or more of 12 different substances (including tobacco, alcohol, and marijuana) during the past month. Response choices were 0, 1 through 2, 3 through 5, 6 through 9, 10 through 19, 20 through 29, and all 30 days.

Descriptive statistics were used to characterize the demographics of study participants, use of indoor tanning facilities, and indoor tanning addiction status. Addiction to indoor tanning was defined as meeting both mCAGE and mDSM-IV-TR criteria for addiction. Study participants with addictive tendencies met the criteria for addiction on either the mCAGE or mDSM-IV-TR. Study participants' frequency of indoor tanning during the past year and affirmative responses to items from the mCAGE and mDSM-IV-TR were computed to determine indoor tanning addiction status. Pearson χ2 tests were used to examine associations among mCAGE, mDSM-IV-TR, and demographic factors (sex and skin type17). Logistic regression models were used to examine study participants' frequency of indoor tanning during the past year, symptoms of anxiety, symptoms of depression, and substance use as predictors of indoor tanning addiction status. Substance use variables included the use of tobacco, alcohol, and marijuana as well as the use of stimulants (ie, cocaine, amphetamines, and/or the nicotine in tobacco). Other substance categories were not analyzed owing to the small number (1-14) of participants who reported substance use; this small number would compromise the validity of the results.18 In addition, use of depressants (alcohol, marijuana, sedatives, and/or opiates) was not analyzed because only 5 participants with addictive tendencies or addiction to indoor tanning did not report use of these substances. Finally, Pearson χ2 tests were used to examine relationships among anxiety, depression, the number of substances used during the past month (excluding alcohol), and lifetime use of indoor tanning devices and tanning addiction status. Alcohol use was excluded from these analyses because only 5 students with addictive tendencies or addiction to indoor tanning did not report alcohol use.

Demographic characteristics of the sample are given in Table 1. When asked whether they had ever tanned indoors, 237 of the 421 study participants (56.3%) answered affirmatively. Data from 8 of the 237 participants who had tanned indoors were omitted from subsequent analyses because of missing values on the mCAGE or mDSM-IV-TR measures. The mean (SD) number of visits to tanning salons during the past year among study participants with a lifetime history of indoor tanning was 23 (24). In addition, data from 70 of the remaining 229 study participants (30.6%) met mCAGE criteria and 90 (39.3%) met mDSM-IV-TR criteria for addiction to indoor tanning. The mCAGE and mDSM-IV-TR results were significantly correlated (κ = 0.43, P < .001; Table 2) and were not significantly associated with sex (P = .12) or skin type (P = .43).

Table Graphic Jump LocationTable 1. Demographic Characteristics of Study Participants
Table Graphic Jump LocationTable 2. Association Between mCAGE and mDSM-IV-TR Findingsa

Frequency of indoor tanning during the past year and affirmative responses to items from the mCAGE and mDSM-IV-TR by tanning addiction status are given in Table 3. Study participants who met criteria for addiction to indoor tanning reported more indoor tanning sessions during the past year than those with addictive tendencies (Table 4). In addition, both groups reported more indoor tanning sessions during the past year than those who did not meet the criteria for addiction to indoor tanning. Clinical categories of anxiety symptoms did not significantly vary as a function of lifetime use of indoor tanning history or tanning addiction status (P = .07; Table 5). However, as indicated in Table 4, study participants who met criteria for addiction to indoor tanning on both the mCAGE and mDSM-IV-TR reported greater symptoms of anxiety than those who did not. Symptoms of depression did not significantly vary by lifetime use of indoor tanning devices or tanning addiction status. When anxiety, depressive symptoms, and frequency of indoor tanning during the past year were included in the same logistic regression model, only frequency of indoor tanning significantly predicted tanning addiction status (addiction vs nonaddiction: Wald χ2=16.55, OR=1.03, P<.001).

Table Graphic Jump LocationTable 3. mCAGE and mDSM-IV-TR Responses and Indoor Tanning Frequency by Tanning Addiction Statusa
Table Graphic Jump LocationTable 4. Predictors of Indoor Tanning Addiction Status
Table Graphic Jump LocationTable 5. Symptoms of Anxiety, Symptoms of Depression, and Substance Use by Lifetime History of Indoor Tanning and Tanning Addiction Statusa

Alcohol use during the past month was affirmed by 210 of 229 study participants (91.7%) who had tanned indoors, whereas 82 (35.8%) and 84 (36.7%) reported use of tobacco and marijuana, respectively, during the past month. Other substances (including cocaine, amphetamines, opiates, and steroids) were used by 1 to 14 students (range = 0.4% to 6.0%) during the past month. Although tobacco use and use of stimulants (cocaine, amphetamines, and/or the nicotine in tobacco) did not differ by tanning addiction status, students who met criteria for addictive tendencies or addiction to indoor tanning reported greater alcohol and marijuana use during the past month than those who did not (Table 4). In addition, the number of substances other than alcohol used during the past month varied by lifetime use of indoor tanning devices and tanning addiction status (Table 5). The highest rate of substance use was found among those who met criteria for addiction to indoor tanning, with 21 of 50 study participants (42.0%) affirming use of 2 or more substances during the past month. Only 29 of 181 study participants who had never tanned indoors (16.0%) and 20 of 119 study participants who tanned indoors and who were not addicted to this behavior (16.8%) affirmed this degree of substance use.

This study provides further support for the notion that tanning may be conceptualized as an addictive behavior for a subgroup of individuals who tan indoors8; it extends prior work by relating indoor tanning addiction to substance use and affective disturbance. Among the 229 study participants who had tanned indoors, 70 (30.6%) met mCAGE criteria and 90 (39.3%) met mDSM-IV-TR criteria for addiction to indoor tanning. Similarly, Poorsattar and Hornung7 found that 28% of undergraduates who had tanned indoors met mCAGE criteria for addiction to tanning. In this study, greater use of indoor tanning devices was associated with greater likelihood of addiction to this behavior, which supports the construct validity of the measures. The lack of association between skin type and addiction to indoor tanning may be attributable to the underrepresentation of darker skin tones. In addition, sex was not associated with addiction to indoor tanning, as in prior research on SRDs that involve UV-light tanning.9,10 Women were overrepresented in this study and previous research9,10; thus, further studies with sex-balanced samples are needed.

An interesting pattern of findings emerged with regard to the relations between substance use and SRDs that involve indoor tanning. Of the 50 study participants who tanned indoors and had positive mDSM-IV-TR and mCAGE responses, 42.0% reported use of 2 or more substances (excluding alcohol) during the past month, whereas 20 (16.8%) of those who tanned indoors and had negative mDSM-IV-TR and mCAGE responses and 29 (16.0%) of those who had never tanned indoors reported this degree of substance use. Furthermore, study participants who met the criteria for addiction to indoor tanning on either the mDSM-IV-TR or mCAGE reported greater use of alcohol and marijuana, compared with those who did not meet these criteria. Other studies11,1820 have found positive associations between substance use and indoor tanning among adolescents and young adults. In this study, tobacco use and the use of stimulants (cocaine, amphetamines, and/or the nicotine in tobacco) did not differ by tanning addiction status, whereas another study9 found a positive association between cigarette smoking and addiction to tanning. Overall, findings suggest that individuals who use drugs may be more likely to develop dependence on indoor tanning because of a similar addictive process. In addition, tanning and drug use may be reinforced by peer group norms.

Anxiety and depression are often comorbid with substance dependence,21 and the present findings suggest that affective disturbance may also be comorbid with dependence on indoor tanning. Specifically, study participants who tanned indoors and had positive mDSM-IV-TR and mCAGE responses had approximately twice the rate of moderate-to-severe anxiety and depressive symptoms than study participants who tanned indoors and had negative responses on both measures and those who had never tanned indoors. Similarly, prior research found a positive association between seasonal affective disorder and indoor tanning frequency.22 In this study, however, anxiety symptoms predicted group classification (ie, affirmative vs negative mDSM-IV-TR and mCAGE responses), whereas depressive symptoms did not predict this classification. In addition, study participants with addictive tendencies (either affirmative mDSM-IV-TR or mCAGE responses) had levels of anxiety and depressive symptoms that did not significantly differ from those who were not addicted to indoor tanning.

If associations between affective factors and indoor tanning behavior are replicated, results suggest that treating an underlying mood disorder may be a necessary step in reducing skin cancer risk among those who frequently tan indoors. Researchers have hypothesized that those who tan regularly year round may require more intensive intervention efforts, such as motivational interviewing, relative to those who tan periodically in response to mood changes or special events.23,24 Further research should evaluate the usefulness of incorporating a brief anxiety and depression screening for individuals who tan indoors. Patients with anxiety or depression could be referred to mental health professionals for diagnosis and treatment.

Limitations of this study include its cross-sectional design and reliance on self-report measures. In addition, the sample consisted of undergraduate students in the northeastern United States; thus, results may not be generalizable across individuals of different age groups, socioeconomic levels, and geographic regions. Although results supported the convergent validity of our new self-report measures of addiction to indoor tanning, the α values were relatively low. These values tend to underestimate reliability, especially when measures contain fewer than 10 items.25 Further reliability testing and in-depth analyses of the measures, such as cognitive interviewing, should be conducted in future studies to strengthen their validity for use with those who tan. For example, use of cognitive interviewing would allow researchers to ascertain whether affirmative responses to item 1a (Table 3) indicate a preoccupation with tanning or agreement with the notion that more time spent tanning darkens the skin. Research is needed to further validate the self-report measures of addiction to indoor tanning by including objective measures of UV radiation exposure (eg, spectrophotometry). It also would be interesting to explore the physiologic and psychological mechanisms underlying the relations among addiction to indoor tanning, other addictive behaviors, and affective disturbance. Such research would inform biopsychosocial conceptualizations of tanning behavior and tailored interventions that address individuals' motivations for tanning and the relation of those motivations to psychopathological conditions.

Correspondence: Catherine E. Mosher, PhD, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 641 Lexington Ave, Seventh Floor, New York, NY 10022 (mosherc@mskcc.org).

Accepted for Publication: November 6, 2009.

Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Mosher and Danoff-Burg. Analysis and interpretation of data: Mosher. Drafting of the manuscript: Mosher. Critical revision of the manuscript for important intellectual content: Mosher and Danoff-Burg. Statistical analysis: Mosher. Obtained funding: Mosher. Administrative, technical, and material support: Mosher and Danoff-Burg. Study supervision: Mosher and Danoff-Burg.

Financial Disclosure: None reported.

Funding/Support: The work of Dr Mosher was supported by grant F32CA130600 from the National Cancer Institute.

Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; or in the preparation, review, or approval of the manuscript.

Previous Presentation: This study was presented in part at the Society of Behavioral Medicine Annual meeting; April 23, 2009; Montreal, Quebec, Canada.

Gallagher  RPSpinelli  JJLee  TK Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev 2005;14 (3) 562- 566
PubMed
Karagas  MRStannard  VAMott  LASlattery  MJSpencer  SKWeinstock  MA Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst 2002;94 (3) 224- 226
PubMed
Veierød  MBWeiderpass  EThörn  M  et al.  A prospective study of pigmentation, sun exposure, and risk of cutaneous malignant melanoma in women. J Natl Cancer Inst 2003;95 (20) 1530- 1538
PubMed
Robinson  JKKim  JRosenbaum  SOrtiz  S Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007. Arch Dermatol 2008;144 (4) 484- 488
PubMed
Feldman  SRLiguori  AKucenic  M  et al.  Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004;51 (1) 45- 51
PubMed
Kaur  MLiguori  ALang  WRapp  SRFleischer  AB  JrFeldman  SR Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006;54 (4) 709- 711
PubMed
Poorsattar  SPHornung  RL UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007;56 (3) 375- 379
PubMed
Nolan  BVTaylor  SLLiguori  AFeldman  SR Tanning as an addictive behavior: a literature review. Photodermatol Photoimmunol Photomed 2009;25 (1) 12- 19
PubMed
Heckman  CJEgleston  BLWilson  DBIngersoll  KS A preliminary investigation of the predictors of tanning dependence. Am J Health Behav 2008;32 (5) 451- 464
PubMed
Warthan  MMUchida  TWagner  RF  Jr UV light tanning as a type of substance-related disorder. Arch Dermatol 2005;141 (8) 963- 966
PubMed
Heckman  CJCoups  EJManne  SL Prevalence and correlates of indoor tanning among US adults. J Am Acad Dermatol 2008;58 (5) 769- 780
PubMed
Mayfield  DMcLeod  GHall  P The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974;131 (10) 1121- 1123
PubMed
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision).  Washington, DC American Psychiatric Association2000;
Beck  ATEpstein  NBrown  GSteer  RA An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988;56 (6) 893- 897
PubMed
Beck  AT Depression Inventory.  Philadelphia, PA Center for Cognitive Therapy1978;
Presley  CAMeilman  PWLyerla  R Development of the Core Alcohol and Drug Survey: initial findings and future directions. J Am Coll Health 1994;42 (6) 248- 255
PubMed
Mahler  HIKulik  JAGibbons  FXGerrard  MHarrell  J Effects of appearance-based interventions on sun protection intentions and self-reported behaviors. Health Psychol 2003;22 (2) 199- 209
PubMed
Cohen  JCohen  PWest  SGAiken  LS Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. 3rd ed. Mahwah, NJ Lawrence Erlbaum Associates2003;
Demko  CABorawski  EADebanne  SMCooper  KDStange  KC Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med 2003;157 (9) 854- 860
PubMed
O'Riordan  DLField  AEGeller  AC  et al.  Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States). Cancer Causes Control 2006;17 (5) 679- 686
PubMed
Hesse  M Integrated psychological treatment for substance use and co-morbid anxiety or depression vs treatment for substance use alone: a systematic review of the published literature. BMC Psychiatry 2009;96
PubMed10.1186/1471-244X-9-6
Hillhouse  JStapleton  JTurrisi  R Association of frequent indoor UV tanning with seasonal affective disorder. Arch Dermatol 2005;141 (11) 1465
PubMed10.1001/archderm.141.11.1465
Hillhouse  JTurrisi  RShields  AL Patterns of indoor tanning use: implications for clinical interventions. Arch Dermatol 2007;143 (12) 1530- 1535
PubMed
Pagoto  SLHillhouse  J Not all tanners are created equal: implications of tanning subtypes for skin cancer prevention. Arch Dermatol 2008;144 (11) 1505- 1508
PubMed
Cortina  JM What is coefficient alpha?: an examination of theory and applications. J Appl Psychol 1993;78 (1) 98- 104

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic Characteristics of Study Participants
Table Graphic Jump LocationTable 2. Association Between mCAGE and mDSM-IV-TR Findingsa
Table Graphic Jump LocationTable 3. mCAGE and mDSM-IV-TR Responses and Indoor Tanning Frequency by Tanning Addiction Statusa
Table Graphic Jump LocationTable 4. Predictors of Indoor Tanning Addiction Status
Table Graphic Jump LocationTable 5. Symptoms of Anxiety, Symptoms of Depression, and Substance Use by Lifetime History of Indoor Tanning and Tanning Addiction Statusa

References

Gallagher  RPSpinelli  JJLee  TK Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev 2005;14 (3) 562- 566
PubMed
Karagas  MRStannard  VAMott  LASlattery  MJSpencer  SKWeinstock  MA Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst 2002;94 (3) 224- 226
PubMed
Veierød  MBWeiderpass  EThörn  M  et al.  A prospective study of pigmentation, sun exposure, and risk of cutaneous malignant melanoma in women. J Natl Cancer Inst 2003;95 (20) 1530- 1538
PubMed
Robinson  JKKim  JRosenbaum  SOrtiz  S Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007. Arch Dermatol 2008;144 (4) 484- 488
PubMed
Feldman  SRLiguori  AKucenic  M  et al.  Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004;51 (1) 45- 51
PubMed
Kaur  MLiguori  ALang  WRapp  SRFleischer  AB  JrFeldman  SR Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006;54 (4) 709- 711
PubMed
Poorsattar  SPHornung  RL UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007;56 (3) 375- 379
PubMed
Nolan  BVTaylor  SLLiguori  AFeldman  SR Tanning as an addictive behavior: a literature review. Photodermatol Photoimmunol Photomed 2009;25 (1) 12- 19
PubMed
Heckman  CJEgleston  BLWilson  DBIngersoll  KS A preliminary investigation of the predictors of tanning dependence. Am J Health Behav 2008;32 (5) 451- 464
PubMed
Warthan  MMUchida  TWagner  RF  Jr UV light tanning as a type of substance-related disorder. Arch Dermatol 2005;141 (8) 963- 966
PubMed
Heckman  CJCoups  EJManne  SL Prevalence and correlates of indoor tanning among US adults. J Am Acad Dermatol 2008;58 (5) 769- 780
PubMed
Mayfield  DMcLeod  GHall  P The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974;131 (10) 1121- 1123
PubMed
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision).  Washington, DC American Psychiatric Association2000;
Beck  ATEpstein  NBrown  GSteer  RA An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988;56 (6) 893- 897
PubMed
Beck  AT Depression Inventory.  Philadelphia, PA Center for Cognitive Therapy1978;
Presley  CAMeilman  PWLyerla  R Development of the Core Alcohol and Drug Survey: initial findings and future directions. J Am Coll Health 1994;42 (6) 248- 255
PubMed
Mahler  HIKulik  JAGibbons  FXGerrard  MHarrell  J Effects of appearance-based interventions on sun protection intentions and self-reported behaviors. Health Psychol 2003;22 (2) 199- 209
PubMed
Cohen  JCohen  PWest  SGAiken  LS Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. 3rd ed. Mahwah, NJ Lawrence Erlbaum Associates2003;
Demko  CABorawski  EADebanne  SMCooper  KDStange  KC Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med 2003;157 (9) 854- 860
PubMed
O'Riordan  DLField  AEGeller  AC  et al.  Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States). Cancer Causes Control 2006;17 (5) 679- 686
PubMed
Hesse  M Integrated psychological treatment for substance use and co-morbid anxiety or depression vs treatment for substance use alone: a systematic review of the published literature. BMC Psychiatry 2009;96
PubMed10.1186/1471-244X-9-6
Hillhouse  JStapleton  JTurrisi  R Association of frequent indoor UV tanning with seasonal affective disorder. Arch Dermatol 2005;141 (11) 1465
PubMed10.1001/archderm.141.11.1465
Hillhouse  JTurrisi  RShields  AL Patterns of indoor tanning use: implications for clinical interventions. Arch Dermatol 2007;143 (12) 1530- 1535
PubMed
Pagoto  SLHillhouse  J Not all tanners are created equal: implications of tanning subtypes for skin cancer prevention. Arch Dermatol 2008;144 (11) 1505- 1508
PubMed
Cortina  JM What is coefficient alpha?: an examination of theory and applications. J Appl Psychol 1993;78 (1) 98- 104

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 29

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
JAMAevidence.com


Addiction