This was a cross-sectional qualitative study of public tweets about indoor tanning during the COVID-19–related shutdowns. We searched Twitter for 2 common lay terms, “tanning bed” and “tanning salon,” that refer to “indoor tanning,” a public health term that refers to tanning using artificial UV light–producing devices [7,15]. Using the R package (R Foundation for Statistical Computing) rtweet, we captured tweets that occurred between March 15, 2020, one of the first days of the COVID-19 statewide business shutdowns, and April 30, 2020 [16,17]. We excluded retweets because our interest was in the original thoughts of users, but we included “quote tweets,” which contain the tweeter’s own sentiments. We removed tweets that were advertisements, pornography, or from accounts that became private or were suspended between the data capture and the qualitative coding process in April 2021 (Figure 1). Of the 5811 tweets captured, we randomly sampled 20% (n=1165) of eligible tweets captured per week during the sampling window to capture conversation from the entire sampling window, consistent with other studies of tweets [18]. Table 1 contains paraphrased tweets to protect the privacy of the users.

We conducted a directed content analysis of tweets using a codebook from our 2016 Twitter study about indoor tanning [7,19]. We modified the codebook after examining a subsample of 100 tweets. The original codebook had 9 codes: a desire to use a tanning bed, sleeping in a tanning bed, tanning-related injury, a complaint about or negative experiences tanning, tanning salon employee chatter, mocking tanners or tanning, health warnings about indoor tanning, pushback against “tanning is unhealthy” messaging or antitanning legislature, and references to indoor tanning in the context of an unrelated topic (eg, movie quote). We expanded the codebook to include 3 additional codes for tweets in which the user expressed that they missed being able to go indoor tanning, expressed a desire to buy a home tanning bed, crowdsourced followers to use a home tanning bed, and mentioned the use of UV tanning alternatives (eg, self-tanners). We eliminated 3 codes (ie, sleeping in a tanning bed, tanning-related injury, a complaint about, or negative experiences) because they were not represented within the current data set. We also coded tweets as posted by people who were likely to indoor tan (based on their admission of tanning or having tanned in their tweets), tanning salon employees (based on the content of their tweets), people who are not likely to indoor tan (based on their mocking indoor tanning or discussing the risks of indoor tanning), and people whose tweets do not indicate if they indoor tan or not. If a tweet seemed to be posted by a tanning salon employee but referred to their individual tanning behavior, we coded the tweet as being posted by someone likely to indoor tan. After finalizing the codebook, 2 coders independently coded all 1165 tweets (100% double-coded). Discrepantly coded tweets were discussed to reach a consensus.

We calculated interrater reliability and Cohen κ for each coding category. Interrater agreement of tweet categories ranged from 94% to 100%, and Cohen κ statistics ranged from 0.6654 to 1.0. Interrater agreement among coders was 94% (κ=0.9106). We summarized the proportion of tweets posted by those likely to indoor tan, tanning salon employees, those unlikely to indoor tan, and those whose tweets do not indicate whether they indoor tan. We then reported the frequency of tweet categories by user types. Analyses were conducted using SAS 9.4 (SAS Institute, Inc).

This study does not meet the definition of human participants research and thus did not require Institutional Review Board approval. However, to protect the privacy of users who may not expect public tweets to be used in research, we paraphrased tweets to render the tweet’s content unsearchable while preserving the meaning. We confirmed that the paraphrased content did not produce the original tweet through searches.

In our final sample of 1165 tweets, 1144 (98%) were posted by unique Twitter accounts. A total of 93% (1084/1165) of tweets in our analytic sample were from the search term “tanning bed,” while only 7% (81/1165) were from the search term “tanning salon.”

Half of the tweets (589/1165, 50.6%) came from users unlikely to indoor tan, while 34.5% (402/1165) were posted by users who seemed likely to indoor tan (Table 1). Very few tweets (4/1165, 0.4%) appeared to be posted by tanning salon employees, and in the remaining 14.5% (170/1165) of tweets, the content did not clearly indicate whether the user was an indoor tanner.

The majority (562/589, 95%) were classified as mocking tanners, tan people, or the act of tanning. Among these, the majority (446/589, 75.7%) mocked former US President Donald Trump’s skin tone, and 20.6% (116/589) mocked the appearance of tanners and the use of tanning beds in general. The remaining 5% (30/589) of tweets from users unlikely to be indoor tanners contained health warnings about indoor tanning.

Nearly two-thirds (260/402, 64.7%) were coded as “missing tanning,” meaning the user expressed they missed tanning, their frustration that they could not go tanning, or their eagerness to get back to tanning (Table 1). Within this category, 60% (156/260) of tweets did not mention a specific reason they missed tanning, but 30% (77/260) indicated they missed indoor tanning for appearance-related reasons, 5% (13/260) indicated they missed indoor tanning for mood-related reasons, and 5% (12/260) indicated withdrawal symptoms from being restricted from indoor tanning. The second most common theme among tweets from likely tanners was general positive attitudes about indoor tanning (69/402, 17.2%), followed by the desire to buy a home tanning bed or use someone else’s (90/402, 22.3%), misinformation about tanning (24/402, 6%), and finally, use of alternative tanning methods such as self-tanner and bronzer makeup (16/402, 3.9%; Table 1).

The content of the remaining tweets (170/174, 98.8%) made it unclear whether the user was an indoor tanner. The vast majority (165/170, 95.9%) mentioned tanning beds in the context of an unrelated topic (eg, movie scene). Tweets posted by tanning salon employees (n=4) were rare and included observations of occurrences in the workplace.

About half of the tweets (589/1165, 50.6%) using the keywords “tanning bed” or “tanning salon” during the COVID-19 pandemic shutdowns in March and April 2020 were not by people who likely use tanning beds. Most of these tweets were mocking people who tan, tanning beds, or the tanned look. The next largest set of tweets (402/1165, 34.5%) seemed to be by people who use tanning beds, as evidenced by their content, which focused on lamenting the inability to tan during the shutdown, expressing the desire for a home tanning bed, expressing positive sentiment about tanning beds, discussing alternative ways to get a tan in the absence of tanning beds, or promoting misinformation.

The finding that only about one-third of tweets (402/1165, 34.5%) appeared to be from indoor tanners is in contrast to a similar investigation by Waring et al [7], where twice the proportion of tweets (699/978, 71.2%) using the same search terms in March 2016 appeared to be from indoor tanners [7]. This finding could be due to declining rates of tanning bed use in recent years [20] or that COVID-19 shutdowns curtailed indoor tanning, which may have decreased chatter about it [20]. Another possibility could be that the proportion of tanning-related tweets that were negative chatter about former US President Donald Trump’s skin color increased from 2016 to 2020 [21-25]. Waring et al [7] found only 10.7% of tweets in 2016 were mocking tanners and the tanned look, compared to 48% (562/1165) of tweets from 2020 in this study. Among tweets that mocked tanners, the vast majority (448/562, 79.7%) mocked former US President Donald Trump, accounting for 38% (446/1165) of all tweets. Criticism of a tan-appearing public figure may shift social norms about indoor tanning for the better or worse, depending on how people feel about that public figure. Perceived social norms strongly predict indoor tanning [26] and increased negative sentiment toward indoor tanning and a tan appearance may shift appearance-related social norms. Future research should explore how negative sentiment on social media about tanned celebrities influences indoor tanning behavior and attitudes.

While most posted tweets lamented the inability to tan, interestingly, very few (16/402, 3.9%) mentioned using tanning alternatives (eg, sunless tanners). Some tanners may have been more interested in gaining access to UV tanning than non-UV tanning, even though the latter was far more accessible. However, those who switched to non-UV tanning may have been less inclined to discuss this on Twitter, perhaps simply because non-UV tanning was more accessible or perhaps to the extent they felt the stigma around admitting to getting a “fake tan” [27,28]. The COVID-19–related shutdowns may have been a missed opportunity to promote sunless tanning products. Because orange-appearing skin was also the focus of tweets mocking Donald Trump (eg, “Trump been in the tanning bed too long? He looks like a Cheeto”), these tweets may have also negatively impacted social norms around sunless tanning products. Many tanners fear sunless tanning products will create an orange appearance because early products had this effect [27,28]. Future research should examine how social norms around tanning beds and sunless tanning are influenced by social media conversations.

The most common type of tweet among tanners expressed that they missed tanning and 39% (260/402) of these mentioned reasons they missed tanning. Appearance-related reasons were by far the most common (77/260, 30%). The increase in the use of videoconferencing software during the COVID-19 pandemic has been shown to have exacerbated appearance-related concerns, leading to an increase in cosmetic surgery consults [29,30]. Because physical appearance is well established to be among the most common reasons people use tanning beds [31,32], future studies should examine how the widespread use of videoconferencing has impacted tanning behavior.

Additional reasons people cited for missing indoor tanning included the positive impact they perceive tanning has on their mood or their discomfort with the negative effect they experience when they are unable to use tanning beds. Research has shown that 8% to 20% of tanners meet criteria for “tanning addiction,” indicators of which may include the experience of mood enhancement from tanning and withdrawal symptoms (eg, irritability) when they cannot tan [33-36]. Future research should explore how the shutdowns may have impacted tanning behavior among people qualifying as “tanning addicted.” The forced period of “cold turkey” could possibly have led some tanners to reduce or quit their tanning habit altogether. Alternatively, when tanning salons reopened, a disinhibition effect may have occurred, such that tanners increased their tanning beyond prepandemic levels after being involuntarily restricted.

Some tweets from tanners (90/402, 22%) expressed their interest in gaining access to a home tanning bed. Future studies should examine whether the small segment of indoor tanners (<10%) who use home beds grew following the pandemic shutdowns [37,38]. The impact of restricted or discouraged access to tanning beds has implications for legislative and public health efforts. For example, Australia banned commercial tanning services in 2016. Governments initiated buyback programs to discourage home tanning bed use in the states of Victoria and New South Wales [39,40]. Afterward, Australian consumer interest in tanning beds declined to less than one-fourth of preban seasonal peaks, but interest in sunless tanning was high [41]. While home tanning beds are still legally marketed in Australia, spray tanning remains more popular [41,42]. Therefore, buyback programs or legislation restricting the sale of home tanning beds may be necessary accompaniments to legislation restricting tanning businesses in the United States.

Unfortunately, we observed very few public health messages regarding the dangers of indoor tanning. Only 2.5% (29/1165) of tweets were of this type, which is even less than the 4.3% that was observed in the previous investigation of tanning bed chatter on Twitter [7]. To be sure, public health efforts were heavily focused on COVID-19 at this time. However, given the misinformation about UV and COVID-19 prevention [14], this would have been an important opportunity to underscore the dangers of indoor tanning. Interestingly, only 5 (0.4%) out of 1165 tweets contained misinformation. Misinformation themes included that UV radiation from tanning beds could kill COVID-19, that UV radiation from the sunbathing could kill COVID-19, and that indoor tanning is healthy to use as therapy. However, because tweets in our study must have contained the words tanning bed or tanning salon, they may not have captured the full range of misinformation circulating about UV and COVID-19.

This study has limitations. Our data capture was limited to 2 common lay terms typically used in the United States to refer to indoor tanning. We may not have captured tweets containing other terms that refer to indoor tanning or tweets about using non-UV tanning alternatives. Additionally, states started reopening at different times during the end of the sampling window, which may have impacted the types of tweets in our sample [43]. Further, we may have captured tweets that were posted by users outside of the United States. Few Twitter users activate their location data [44], so it is difficult to determine where all the tweets originated. As we only coded 1165 tweets from the nearly 5000 unique tweets captured during the sampling window, we may have missed interesting yet rare topics of conversation. Additionally, tanners who were most upset by the shutdowns may have been more likely to tweet about them. Among the 23% of adults in the United States that use Twitter, only 18% reside in rural areas [45,46], so our data may not have captured the full range of sentiment about indoor tanning in rural areas of the United States.

Many indoor tanners appeared to miss indoor tanning during the pandemic shutdown, particularly due to appearance concerns, and some were seeking alternative ways to access tanning beds. We also discovered that, compared to a similar investigation 5 years ago, a much larger percentage of tweets about indoor tanning were very critical of indoor tanning [7]. The use of tanning beds or the appearance of having used them appears to be the target of insults that are often politically motivated on social media. Future research is needed to examine how the pandemic and the surrounding political climate affected tanning behavior and attitudes.