Sunbathing habits and sunscreen use among white adults: results of a national survey

Sex differences in the association between tumor growth and T cell response in a melanoma mouse model

Epidemiological evidence suggests that females have an advantage over males in cases of melanoma incidence, progression, and survival. However, the biological mechanisms underlying these sex differences remain unclear. With the knowledge that females generally have a more robust immune system than males, we investigated sex differences in melanoma progression in a B16-F10/BL6 syngeneic mouse model. We observed significantly less tumor volume and growth rate over 14 days in female mice compared to male mice. Furthermore, higher populations of CD4⁺ and CD8⁺ T cells, which indicate adaptive immune responses, were found in the circulating blood and tumors of females and corresponded with less tumor growth, and vice versa in males. Our results highlight a mouse model that represents melanoma progression in the human population and displays a higher immune response to melanoma in females compared to males. These findings suggest that the immune system may be one of the mechanisms responsible for sex differences in melanoma.

Differences in reported sun protection practices, skin cancer knowledge, and perceived risk for skin cancer between rural and urban high school students

PURPOSE

The purpose of the current study was to evaluate differences in reported use of sun protection, tanning behaviors, skin cancer-related knowledge, and perceived risk between rural and urban high school students in a geographic area with high rates of melanoma.

METHODS

A total of 1,570 high school students (56.8% female) from urban (6 schools) and rural (7 schools) geographic areas in Utah completed questionnaires assessing sun protection and tanning behaviors, skin cancer-related knowledge, and perceived risk for skin cancer. Analyses examined potential differences in these outcomes between rural and urban students and by gender.

RESULTS

Compared to students in urban areas, those in rural areas had lower odds of wearing sunscreen (OR 0.71; 95% CI 0.53, 0.95; p = 0.022), re-applying sunscreen (OR 0.61; 95% CI 0.74, 1.02; p = 0.002), wearing long-sleeved shirts (OR 0.63 95% CI 0.46, 0.86; p = 0.004), and seeking shade (OR 0.67; 95% CI 0.50, 0.88; p = 0.005).

CONCLUSIONS

Rural students reported less adequate use of sun protection than urban students. Rural male students reported lower knowledge scores compared to urban males. Future skin cancer prevention efforts targeting rural high schoolers are warranted.

In vivo determination of the skin surface topography and biophysical properties of human hands: Effects of sex and hand dominance

BACKGROUND

The effect of hand dominance on the skin topography and parameters associated with skin health and aging is unknown.

METHODS

Healthy adult volunteers were recruited. The following four strata were enrolled: Group 1: male, right handed; Group 2: male, left handed; Group 3: female, right handed; and Group 4: female, left handed. The differences between groups on their surface evaluation of living skin (SELS) parameters were evaluated. These variables included (a) roughness (SER); (b) smoothness (SESM); (c) scaliness (SESC); and (d) wrinkles (SEW).

RESULTS

A total of twenty subjects were recruited, with five in each stratum. Significant differences between groups were found for SESC [F(7,31) = 2.742, P = .024, partial eta squared = 0.382] and SEW [F(7,31) = 3.705, P = .005, partial eta squared = 0.456]. An evaluation of the descriptive statistics revealed that males had a higher mean SESC value than females and a lower mean SEW value. Moreover, the dominant hand of both sexes had a higher mean SEW value than non-dominant hands.

CONCLUSIONS

Given the evidence of sex and handedness differences in wrinkle genesis and desquamation severity, these factors should be considered in the dermatological treatment and counseling of patients.

UV exposure, preventive habits, risk perception, and occupation in NMSC patients: A case-control study in Trieste (NE Italy)

BACKGROUND

UV exposure is strongly associated with the incidence of non melanoma skin cancers (NMSCs), both basal and squamous cell carcinomas. The aim of our study was to analyze risk perception, UV exposure, preventive habits, and occupation in 126 subjects affected by NMSC and 187 controls.

METHODS

Consecutive cases with incident NMSC were recruited in Dermatologic Unit at University of Trieste; controls were recruited in Unit of Occupational Medicine. All had a medical examination to define Fitzpatrick skin type and skin lesions, and filled a standardized questionnaire on sun exposure habits, sun protection, occupational exposures, and sunburns in adulthood and childhood.

RESULTS

In multivariate regression analysis, NMSC resulted significantly associated with age (OR: 1.03; 95% CI 1.01-1.05), with a positive feeling for tan (OR: 1.10; 95% CI 1.01-1.20), and sunbath numbers per year (OR: 1.02; 95% CI: 1.001-1.03). A protective effect was demonstrated for Fitzpatrick phototypes III-IV compared to I and II (OR: 0.31; 95% CI: 0.18-0.55), sunscreen use (OR: 0.35; 95% CI: 0.22-0.58), and risk perception (OR: 0.98; 95% CI: 0.97-0.99). In univariate analysis, we demonstrated an increased risk for fishermen, sailors, and lifeguards (OR: 4.3; 95% CI: 1.1-16.4); foundry and metallurgy workers (OR: 5.58; 95% CI: 1.14-27.3); and mechanics, fixers, and welders (OR: 8.2; 95% CI: 1.76-37.9).

CONCLUSIONS

Our study demonstrated that protective behavior must be implemented in people living in Trieste. Workers must avoid direct UV exposure and must use protective equipment. More efforts are needed to increase knowledge on this risk and to raise awareness among at-risk people.

Knowledge and Attitude of General Population toward Effects of Sun Exposure and Use of Sunscreens

Background

Sun exposure causes extensive intrinsic as well as extrinsic changes in the skin. Pathogenic effects of sun exposure such as tanning, melasma, skin cancer, and aggravation of various photodermatoses such as systemic lupus erythematosus (SLE) may be prevented by the use of sunscreens. We conducted the present study to assess the knowledge and attitudes regarding sun exposure and use of sunscreens.

Methods

Two thousand and thirty-seven volunteers answered the questionnaire over a period of 2 years. All adults aged 18 years and above who voluntarily agreed to participate in the study after written informed consent were included.

Results

Out of 2037 volunteers, 1242 volunteers had no knowledge of sunscreens. Sixty-eight percent of the volunteers from the upper class of society knew about sunscreens, and 86% of the volunteers from the lower middle class did not know about sunscreens. Eight-one percent of the volunteers did not suffer from sunburns. Eight-four percent of the volunteers were aware that sun exposure caused darkening, but awareness about other effects of sun exposure such as wrinkling, melasma, allergy, and photo-induced cancers was less. Most of the volunteers agreed that sunscreens protected against sun damage and tanning. Fifty-eight percent of the volunteers applied sunscreen before venturing out, and 78% of the volunteers applied sunscreen only on the face. Prevention of tanning was the most common reason for the usage of sunscreens. Cosmetic appeal and irritant potential were the prominent deciding factors in choosing sunscreens.

Conclusion

Awareness about protective spectrum of sunscreens, their correct method of application, and misconceptions need to be focused on. Better product development keeping in mind the Indian conditions would help in increasing the usage of sunscreens.

Fostering multiple healthy lifestyle behaviors for primary prevention of cancer

The odds of developing cancer are increased by specific lifestyle behaviors (tobacco use, excess energy and alcohol intakes, low fruit and vegetable intake, physical inactivity, risky sexual behaviors, and inadequate sun protection) that are established risk factors for developing cancer. These behaviors are largely absent in childhood, emerge and tend to cluster over the life span, and show an increased prevalence among those disadvantaged by low education, low income, or minority status. Even though these risk behaviors are modifiable, few are diminishing in the population over time. We review the prevalence and population distribution of these behaviors and apply an ecological model to describe effective or promising healthy lifestyle interventions targeted to the individual, the sociocultural context, or environmental and policy influences. We suggest that implementing multiple health behavior change interventions across these levels could substantially reduce the prevalence of cancer and the burden it places on the public and the health care system. We note important still-unresolved questions about which behaviors can be intervened upon simultaneously in order to maximize positive behavioral synergies, minimize negative ones, and effectively engage underserved populations. We conclude that interprofessional collaboration is needed to appropriately determine and convey the value of primary prevention of cancer and other chronic diseases.

Prevalence of sun exposure and its associated factors in southern Brazil: a population-based study

BACKGROUND

Sunlight exposure is responsible for a large number of dermatological diseases.

OBJECTIVE

We estimated the prevalence of sunlight exposure and its associated factors in adults from southern Brazil in a cross-sectional, population-based study.

METHODS

We investigated a representative sample of individuals aged ≥ 20 years (n=3,136). Sunlight exposure and its associated factors were evaluated in two distinct situations: at leisure time and at work. The time period investigated ranged from December 2004 to March 2005, comprising 120 days of the highest ultraviolet index in the urban area of the city of Pelotas, in southern Brazil. The participants were asked about sunlight exposure for at least 20 minutes between 10 A.M. and 4 P.M. The analysis was stratified by sex, and sunlight exposure was grouped into five categories.

RESULTS

Among the 3,136 participants, prevalence of sunlight exposure at the beach was 32.8% (95% CI, 30.3 - 35.2) and 26.3% (95% CI, 24.2 28.3) among men and women, respectively. The prevalence at work was 39.8% (95% CI, 37.2 - 42.4) among men and 10.5% (95% CI, 9.1 - 12.0) among women. Age was inversely associated with sunlight exposure. Family income and achieved schooling were positively associated with sunlight exposure at leisure time and inversely associated with sunglight exposure at work. Self-reported skin color was not associated. Knowledge of any friend or relative who has been affected by skin cancer was positively associated with sunlight exposure among men at work.

CONCLUSION

Despite the media campaigns on the harmful effects of excessive sunlight exposure, we found a high prevalence of sunlight exposure during a period of high ultraviolet index.

Evaluating a measure of tanning abuse and dependence

OBJECTIVE

To evaluate the Structured Interview for Tanning Abuse and Dependence (SITAD).

DESIGN

Longitudinal survey.

SETTING

College campus.

PARTICIPANTS

A total of 296 adults.

MAIN OUTCOME MEASURES

The SITAD modified items from the Structured Clinical Interview for DSM-IV Axis I Disorders that focus on opiate abuse and dependence. Indoor tanning (IT) behavioral patterns and opiate-like reactions to tanning were measured, and IT behavior was measured 6 months later.

RESULTS

Of 296 participants, 32 (10.8%) met the SITAD criteria for tanning abuse (maladaptive pattern of tanning as manifested by failure to fulfill role obligations, physically hazardous tanning, legal problems, or persistent social or interpersonal problems) and 16 (5.4%) for tanning dependence as defined by 3 or more of the following: loss of control, cut down, time, social problems, physical or psychological problems, tolerance, and withdrawal. The IT frequency in dependent tanners was more than 10 times the rate in participants who do not meet the SITAD criteria for tanning abuse or dependence. Tanning-dependent participants were more likely to report being regular tanners (75%; odds ratio, 7.0). Dependent tanners scored higher on the opiate-like reactions to tanning scale than did abuse tanners, who scored higher than those with no diagnosis.

CONCLUSIONS

The SITAD demonstrated some evidence of validity, with tanning-dependent participants reporting regular IT, higher IT frequency, and higher scores on an opiate-like reactions to tanning scale. A valid tanning dependence screening tool is essential for researchers and physicians as a tanning-dependent diagnosis may facilitate a better understanding of tanning motivations and aid in the development of efficacious intervention programs.

Contralateral distribution of nonmelanoma skin cancer between older Hispanic/Latino and non-Hispanic/non-Latino individuals

BACKGROUND

 A recent review of the SEER database revealed that melanoma and Merkel cell carcinoma occur more commonly on the left side of the body. Similarly, a trend was reported in which nonmelanoma skin cancers (NMSCs) were found to be distributed more frequently on the left side of the body.

OBJECTIVES

 To compare the sidedness of NMSC in a large patient population. There were five primary objectives of the present study: (i) to confirm or refute the left-sided trend of NMSC in the largest patient population studied for asymmetry to date; (ii) to determine whether the left-sided trend existed in Hispanic/Latino individuals; (iii) to examine skin cancer in older individuals across ethnicities; (iv) to compare distribution across anatomical location and ethnicity; and (v) to measure gender differences in the distribution of NMSC.

METHODS

 The last 3026 cases referred to the Mohs surgical unit at the University of Miami Miller School of Medicine during 2008-2011 were reviewed. The patient's age, gender, tumour side, tumour type, anatomical location and ethnicity were recorded.

RESULTS

 There were 1505 (50·2%) right-sided tumours and 1495 (49·8%) left-sided tumours (P=0·52). The Hispanic/Latino group had a nonsignificant right-sided trend with 607 (52·7%) right-sided cases and 545 (47·3%) left-sided cases (P=0·06). The non-Hispanic/non-Latino group between the ages of 60 and 85 years had 605 (46·9%) right-sided tumours and 686 (53·1%) left-sided tumours (P=0·024). The Hispanic/Latino group between the ages of 60 and 85 years demonstrated 404 (54·0%) right-sided tumours and 344 (46·0%) left-sided tumours (P=0·028). One hundred and fifty-four skin cancers were located on the upper extremities of non-Hispanic/non-Latino individuals with 64 (41·6%) being right sided and 90 (58·4%) left sided (P=0·036). Seventy-eight skin cancers were located on the upper extremities of Hispanic/Latino individuals with 49 (62·8%) being right sided and 29 (37·2%) left sided (P=0·024). Males had most of the skin cancers at 2125 (70·8%) cases and females had 875 (29·2%) cases (P<0·001).

CONCLUSIONS

 NMSC appears to be more common on the left side of older non-Hispanic/non-Latino individuals, while it is more common on the right side of older Hispanic/Latino individuals. This is likely to be secondary to an environmental factor, such as ultraviolet radiation. NMSC is significantly more common in males relative to females, which may be attributed to differences in gender roles or referral practices.

Actinic skin damage and mortality--the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study

BACKGROUND

Exposure to sunlight may decrease the risk of several diseases through the synthesis of vitamin D, whereas solar radiation is the main cause of some skin and eye diseases. However, to the best of our knowledge, the association of sun-induced skin damage with mortality remains unknown.

METHODOLOGY/PRINCIPAL FINDINGS

Subjects were 8472 white participants aged 25-74 years in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Cardiovascular disease mortality, cancer mortality, and all-cause mortality were obtained by either a death certificate or a proxy interview, or both. Actinic skin damage was examined and recorded by the presence and severity (absent, minimal, moderate, or severe) of overall actinic skin damage and its components (i.e., fine telangiectasia, solar elastosis, and actinic keratoses). Cox regression and Kaplan-Meier methods were applied to explore the associations. A total of 672 cancer deaths, 1500 cardiovascular disease deaths, and 2969 deaths from all causes were documented through the follow-up between 1971 and 1992. After controlling for potential confounding variables, severe overall actinic skin damage was associated with a 45% higher risk for all-cause mortality (95% CI: 1.22, 1.72; P<0.001), moderate overall skin damage with a 20% higher risk (95% CI: 1.08., 1.32; P<0.001), and minimal overall skin damage with no significant mortality difference, when compared to those with no skin damage. Similar results were obtained for all-cause mortality with fine telangiectasia, solar elastosis, and actinic keratoses. The results were similar for cancer and cardiovascular disease mortality.

CONCLUSIONS

The present study gives an indication of an association of actinic skin damage with cardiovascular disease, cancer and all-cause mortality in white subjects. Given the lack of support in the scientific literature and potential unmeasured confounding factors, this finding should be interpreted with caution. More independent studies are needed before any practical recommendations can be made.

A 5-year Retrospective Review of Asian Ectropion: How Does It Compare to Ectropion Amongst Non-Asians?

Introduction: This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes. Materials and Methods: Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Pre- and postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis. Results: Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes. Conclusions: Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians. Keywords: Asian eyes, Lateral tarsal strip

Interaction of area-level socioeconomic status and UV radiation on melanoma occurrence in California

BACKGROUND

Melanoma incidence has been correlated strongly and positively with both socioeconomic status (SES) and lower latitude and other measures of ambient UV radiation (UVR). However, because high-SES populations may be colocated in areas of high UVR, we assessed their joint influences on melanoma occurrence to better target subpopulations for melanoma education and screening.

METHODS

We obtained from the California Cancer Registry information regarding 23,564 incident cases of invasive cutaneous melanoma among non-Hispanic white residents between January 1, 1998, and December 31, 2002. We geocoded each case based on residence at diagnosis and linked previously tested neighborhood measures of SES and average annual UVR to calculate age-adjusted incidence rates, rate ratios, and the corresponding 95% confidence intervals. Poisson regression was used to calculate multivariately adjusted rate ratios.

RESULTS

UVR was significantly and positively associated with melanoma incidence only among persons living in the top 40% of California neighborhoods ranked by SES. People in neighborhoods of the highest SES and UVR categories had 60% higher rates of melanoma than those from neighborhoods in the lowest categories (rate ratio, 1.60; 95% confidence interval, 1.02-2.51).

CONCLUSION

Our findings indicate that UVR and SES interact to influence melanoma occurrence and suggest that socioeconomic gradients in melanoma incidence are not explained entirely by UVR.

IMPACT

Cancer prevention and early detection educational efforts should be targeted to high-SES groups in areas of high UVR exposure. Contextual measures of both SES and UVR should be considered important determinants of melanoma occurrence in future studies.

Predictors of sun protection behaviors and severe sunburn in an international online study

BACKGROUND

The incidence of melanoma continues to increase in many countries, and primary prevention of melanoma includes avoidance of sunburn as well as adequate sun protection behavior. The aim of this study was to examine the prevalence of self-reported sun protection behaviors and sunburn in users of the Internet, and to identify the demographic, clinical, and attitudinal/motivational correlates of sun protection behaviors.

METHODS

Self-report data were gathered on behalf of the GenoMEL consortium using an online survey available in 10 different languages, and 8,178 individuals successfully completed at least 80% of survey items, with 73% of respondents from Europe, 12% from Australia, 7% from the United States, 2% from Israel, and 6% from other countries.

RESULTS

Half of all respondents and 27% of those with a previous melanoma reported at least one severe sunburn during the previous 12 months. The strongest factors associated with sun protection behavior were perceived barriers to protection (beta = -0.44/beta = -0.37), and respondents who reported a positive attitude toward suntans were less likely to protect (beta = -0.16/beta = -0.14). Reported use of protective clothing and shade, as well as avoidance of midday sun exposure, were more strongly related to reduced risk of sunburn than sunscreen use.

CONCLUSIONS

Despite widespread dissemination of public health messages about the importance of sun protection, a substantial proportion of this international sample, including respondents with a previous melanoma, reported inadequate sun protection behaviors resulting in severe sunburn.

IMPACT

Future strategies to decrease sunburn should target the practical, social, and psychological barriers associated with nonuptake of sun protection.

Predictors of sun protection behaviors and severe sunburn in an international online study

BACKGROUND

The incidence of melanoma continues to increase in many countries, and primary prevention of melanoma includes avoidance of sunburn as well as adequate sun protection behavior. The aim of this study was to examine the prevalence of self-reported sun protection behaviors and sunburn in users of the Internet, and to identify the demographic, clinical, and attitudinal/motivational correlates of sun protection behaviors.

METHODS

Self-report data were gathered on behalf of the GenoMEL consortium using an online survey available in 10 different languages, and 8,178 individuals successfully completed at least 80% of survey items, with 73% of respondents from Europe, 12% from Australia, 7% from the United States, 2% from Israel, and 6% from other countries.

RESULTS

Half of all respondents and 27% of those with a previous melanoma reported at least one severe sunburn during the previous 12 months. The strongest factors associated with sun protection behavior were perceived barriers to protection (beta = -0.44/beta = -0.37), and respondents who reported a positive attitude toward suntans were less likely to protect (beta = -0.16/beta = -0.14). Reported use of protective clothing and shade, as well as avoidance of midday sun exposure, were more strongly related to reduced risk of sunburn than sunscreen use.

CONCLUSIONS

Despite widespread dissemination of public health messages about the importance of sun protection, a substantial proportion of this international sample, including respondents with a previous melanoma, reported inadequate sun protection behaviors resulting in severe sunburn.

IMPACT

Future strategies to decrease sunburn should target the practical, social, and psychological barriers associated with nonuptake of sun protection.

Melanoma risk factors, perceived threat and intentional tanning: an international online survey

Cutaneous melanoma continues to increase in incidence in many countries, and intentional tanning is a risk factor for melanoma. The aim of this study was to understand how melanoma risk factors, perceived threat and preferences for a suntan relate to intentional tanning. Self-report data were collected on behalf of GenoMEL (www.genomel.org) from the general population using an online survey. A total of 8178 individuals completed the survey, with 72.8% of respondents being from Europe, 12.1% from Australia, 7.1% from the US, 2.5% from Israel and 5.5% from other countries. Seven percent of respondents had previously been diagnosed with melanoma and 8% had at least one first-degree relative with a previous melanoma. Overall, 70% reported some degree of intentional tanning during the past year, and 38% of respondents previously diagnosed with melanoma had intentionally tanned. The total number of risk factors was positively correlated with perceived risk of melanoma [correlation coefficient (rho) = 0.27], and negatively correlated with intentional tanning (rho = -0.16). Preference for a dark suntan was the strongest predictor of intentional tanning [regression coefficient (beta) = 0.35, P<0.001], even in those with a previous melanoma (beta = 0.33, P<0.01). A substantial proportion of participants reported having phenotypic and behavioural risk factors for melanoma. The preference regarding suntans seemed more important in the participants' decision to intentionally tan than their perceived risk of developing melanoma, and this finding was consistent among respondents from different countries. The drive to sunbathe to tan is a key factor to be moderated if melanoma incidence is to be reduced.

Estimated equivalency of vitamin D production from natural sun exposure versus oral vitamin D supplementation across seasons at two US latitudes

BACKGROUND

The relationship between oral vitamin D supplementation and cutaneous photosynthesis is not well understood.

OBJECTIVE

We sought to provide estimates of the equivalency of vitamin D production from natural sun exposure versus oral supplementation.

METHODS

Using the FastRT simulation tool, we determined sun exposure times needed to achieve serum vitamin D(3) concentrations equivalent to 400 or 1000 IU vitamin D for individuals of various Fitzpatrick skin types living in Miami, FL, and Boston, MA, during the months of January, April, July, and October.

RESULTS

Peak ultraviolet B irradiation for vitamin D synthesis occurs around 12 pm Eastern Standard Time (EST). In Boston, MA, from April to October at 12 pm EST an individual with type III skin, with 25.5% of the body surface area exposed, would need to spend 3 to 8 minutes in the sun to synthesize 400 IU of vitamin D. It is difficult to synthesize vitamin D during the winter in Boston, MA. For all study months in Miami, FL, an individual with type III skin would need to spend 3 to 6 minutes at 12 pm EST to synthesize 400 IU. Vitamin D synthesis occurs faster in individuals with lighter Fitzpatrick skin types. The duration to attain 1000 IU of vitamin D is longer in all scenarios.

LIMITATIONS

Results of the computer model are only approximations. In addition, calculations were made based on the assumption that (1/4) of 1 minimal erythema dose directed at (1/4) body surface area is equal to 1000 IU of oral vitamin D.

CONCLUSIONS

Although it may be tempting to recommend intentional sun exposure based on our findings, it is difficult, if not impossible to titrate one's exposure. There are well-known detrimental side effects of ultraviolet irradiation. Therefore, oral supplementation remains the safest way for increasing vitamin D status.

Adolescent attitudes towards tanning: does age matter?

Adolescents seem to be obsessed with tanning. One third of both adolescents and adults report sunbathing. On average, about 20% of adolescents report ever-using of artificial UV tanning devices with 15% currently using them. Tanning attitudes appear similar for adolescents and adults. The top three reasons for tanning included beliefs that a tan makes them more comfortable socializing with friends, looks better and is attractive. The top reason for using artificial UV tanning devices is also aesthetics, followed by relaxation. Other reasons for using artificial UV tanning devices include vacation preparation and to gain a protective base. Attitudes related to appearance that result in more frequent tanning may be difficult to change.

Skin cancer-related prevention and screening behaviors: a review of the literature

Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of skin cancer. The aim of this systematic review was to provide a comprehensive overview of the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three decades were reviewed and synthesized. Reported estimates of sunscreen use varied considerably across studies, ranging from 7 to 90%. According to self-report, between 23 and 61% of individuals engage in skin self-examination at least once per year, and the documented prevalence of annual clinical skin examination ranges from 8 to 21%. Adherence to sun protection and screening recommendations is associated with a range of factors, including: female gender, sun-sensitive phenotype, greater perceived risk of skin cancer, greater perceived benefits of sun protection or screening, and doctor recommendation for screening. The literature suggests that a large proportion of the general population engage in suboptimal levels of sun protection, although there is substantial variability in findings. The strongest recommendation to emerge from this review is a call for the development and widespread use of standardized measurement scales in future research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer.

Melanoma epidemiology and public health

This article reviews the research on, and examines the epidemiology and prevention of melanoma. Despite the great quantity of research into environmental and genetic causes, and the ease of diagnosis, incidence and mortality have risen in all developed countries during the last half century. Patient and physician education, and public health programs aimed at prevention, have had varied success. The authors conclude that, until we have better data on how to prevent skin cancer of all types, the best solutions are education of high-risk populations about skin self-evaluation in combination with physician examination to practice; and sun protection.

Better the Devil You Know? High-Risk Individuals’ Anticipated Psychological Responses to Genetic Testing for Melanoma Susceptibility

PURPOSE

The psychological consequences of genetic testing for mutations among individuals at increased risk of developing melanoma remain unexamined. The present study aimed to explore anticipated emotional, behavioral, cognitive, and familial responses to hypothetical genetic testing for melanoma susceptibility.

METHODS

Forty semi-structured interviews were undertaken with affected (n=20) and unaffected (n=20) individuals at either high or average risk of developing melanoma due to family history.

RESULTS

In-depth thematic analysis revealed that, in response to being identified as a mutation carrier, most participants with a family history anticipated calmly accepting their increased risk; either increasing precaution adoption or maintaining already vigilant behavioral practices; perceiving such information as important and valuable; and communicating genetic test results to family members, despite the acknowledgement of potential difficulties. In response to being identified as a non-carrier, the majority of participants expected to feel relieved; to maintain current precautionary health practices; to still perceive themselves at some risk of developing melanoma; and to be wary of the potential negative behavioral consequences of disclosing such information to family members. Women appeared more likely than men to acknowledge the potential for depression and worry following genetic testing. In contrast, more males than females expected to carry a gene mutation, and viewed their current preventive practices as optimum.

CONCLUSION

Genetic testing for melanoma risk is likely to elicit a complex array of emotional, behavioral, cognitive, and familial responses for both testees and their family members, and these responses are likely to bear subtle differences for males and females.

Sun protective behaviors and sunburn experiences in parents of youth ages 11 to 18

BACKGROUND

Recent studies suggest that parental sun protective behaviors and communication influence their adolescents. However, there is limited information on sun protection for parents of adolescents.

METHODS

A telephone-based, nationally representative prevalence study of sun exposure among youth, aged 11-18, and their parents living in households was conducted in 1998. Separate, independent responses were collected. Weighted prevalence estimates and 95% confidence intervals were estimated and presented for parents only (n = 1187).

RESULTS

Approximately one-third of parents planned activities to avoid the sun and used sunscreen. Among parents who used sunscreen, 70% applied it while at the beach or pool, but not as often during other outdoor activities. Almost one-third of parents were participating in water or non-water recreational activities during their most serious sunburn. Differences in sun protection and sunburn experiences were observed by age, gender, sun sensitivity, race and ethnicity, and educational attainment.

CONCLUSIONS

Parents have adopted sun protection habits, but have not surpassed national sun-protection goals. Combined use of sun protection behaviors may reduce sunburn prevalence and number of incident skin cancers. These data may be useful for developing or enhancing current sun protection programs for effective sun protection that include parents and their adolescents.

Evaluation of sun-protective practices of organ transplant recipients

The incidence, morbidity and mortality of skin cancer are markedly increased in organ transplant recipients. Efforts aimed at reducing sun exposure through sun avoidance, sunscreens and sun-protective clothing are the most effective means to reduce the risk of skin cancer. We evaluated the sun-protective behaviors of 205 transplant recipients. Twenty-three percent of transplant patients continued to seek a tan. Thirty percent of patients did not use sunscreens, and of those patients who did, less than 5% were committed to using them daily. Thirty-seven percent of patients frequently wore hats and 39% of patients frequently wore additional clothing to block the sun. When data were stratified according to patient age, gender or skin phototype, we identified preferences for specific sun-protective methods. These data strongly suggest that many transplant recipients do not use adequate sun protection. Further study of strategies to encourage the use of sun protection among transplant patients is needed to reduce the incidence of skin cancer.

Development and reliability of a brief skin cancer risk assessment tool

This study aimed to develop and pilot test a brief skin cancer risk assessment tool (BRAT), a self-administered instrument that can be reliably used to assess skin cancer risk. To develop the BRAT, we critically reviewed published literature on risk factors; formulated a draft questionnaire; pilot tested the questionnaire; and retested 1 month later. The BRAT items address the key risk factors for melanoma and other keratinocyte skin cancers: ethnicity, personal and family history of skin cancer, mole count, freckles, childhood residence, sunburn history, and sun sensitivity factors (skin color, natural hair color, ease of sunburning and tanning). One hundred sixty-five persons completed the initial BRAT pilot study, and 52 additional people at moderate- or high-risk completed a second BRAT pilot study. Results were as follows: using a dichotomous risk measure, about 90% of subjects would be correctly classified at baseline and follow-up. Weighted kappa for the total BRAT score (0.41-0.68) and for individual items (0.57-0.99) were fair to good, as were correlation coefficients. The BRAT has acceptable to good reproducibility. Reliability statistics compared favorably with those reported in the literature for similar measures.

Gender differences in young adults' beliefs about sunscreen use

This study employs focus group methodology to explore gender differences in sunscreen use. Guided by the theory of reasoned action, males and females were found to differ on each of the following constructs: behavior, behavioral beliefs, and normative beliefs. Males and females differed in their sunscreen use, with females adopting a more preventive style of sunscreen use and males a more reactive style. Males and females differed in their salient beliefs that motivated their sunscreen use, many of which were related to traditional American gender roles. In addition, although males and females were aware of both positive and negative sources of normative beliefs regarding sunscreen use, females received more encouragement from their mothers and peers than males. Findings are discussed in terms of their implications for the design of future interventions.

Skin cancer prevention: education and public health issues

OBJECTIVES

To examine current public health initiatives related to skin cancer prevention and early detection, and public education issues.

DATA SOURCES

Review articles, research reports, web sites, and government reports.

CONCLUSIONS

Skin cancer remains a major public health problem. Efforts to decrease the morbidity and mortality associated with skin cancer are gradually shifting toward primary prevention. Primary prevention efforts should not only be limited to using sunscreen, but should also focus on reductions in ultraviolet light exposure. Secondary prevention efforts include professional skin examinations and skin self-examination. Tertiary efforts focus on the prevention and detection of additional primary skin cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can influence the public to practice primary, secondary, and tertiary prevention strategies for skin cancer.

Sunburn reduction through parental role modeling and sunscreen vigilance

OBJECTIVES

To identify characteristics associated with child sunburn experience and sun protection practices, including parent and child demographics, phenotype, and sun-related knowledge, attitudes, and behaviors.

STUDY DESIGN

A nationally representative telephone survey conducted in 1999 with 651 parents of children 5 to 12 years of age to collect data relating to the sun-related knowledge, attitudes, and behaviors of the parent and child.

RESULTS

Nearly half of parents (49%) and children (44%) were sunburnt during the previous summer. Parents who reported that they had been sunburnt were more likely to have children who had been sunburnt (OR = 2.9, 95% CI = 2.0, 4.2). Conversely, parents with a high level of sun protection behavior were less likely to report being sunburnt (OR = 0.6, 95% CI = 0.4, 0.9), and their children were more likely to have a high level of sun protection behavior (OR = 3.0, 95% CI = 2.0, 4.6) and sunscreen vigilance (OR = 2.7, 95% CI = 1.7, 4.5). High sunscreen vigilance was associated with a 60% reduction in child sunburning.

CONCLUSIONS

The sunburn experience and sun protection practices of children (5-12 years of age) are closely linked to a number of modifiable attitudes and behaviors of their parents. Therefore the inclusion of parents and care givers in interventions targeting children may increase program efficacy.

Use of sunscreen, sunburning rates, and tanning bed use among more than 10 000 US children and adolescents

OBJECTIVES

To describe the association of sunscreen use, sunburning, and tanning bed use by age, sex, residence, and psychosocial variables associated with tan-seeking behaviors, and to compare these findings with sun protection recommendations from federal agencies and cancer organizations.

METHODS

A cross-sectional study, from all 50 states, of 10 079 boys and girls 12 to 18 years of age in 1999. Data were collected from self-report questionnaires with the children of the participants from the Nurses Health Study (Growing Up Today Study).

RESULTS

The prevalence of sunscreen use was 34.4% with girls more likely to use sunscreen than boys (40.0 vs 26.4, odds ratio: 1.86; 95% confidence interval: 1.70-2.03). Eighty-three percent of respondents had at least 1 sunburn during the previous summer, and 36% had 3 or more sunburns. Nearly 10% of respondents used a tanning bed during the previous year. Girls were far more likely than boys to report tanning bed use (14.4 vs 2.4), and older girls (ages 15-18) were far more likely than younger girls (ages 12-14) to report tanning bed use (24.6% vs 4.7). Tanning bed use increased from 7% among 14-year-old girls to 16% by age 15, and more than doubled again by age 17 (35%; N = 244). Multivariate analysis demonstrated that attitudes associated with tanning, such as the preference for tanned skin, having many friends who were tanned, and belief in the worth of burning to get a tan, were generally associated with sporadic sunscreen use, more frequent sunburns, and increased use of tanning beds.

CONCLUSIONS

Our findings suggest that many children are at subsequent risk of skin cancer because of suboptimal sunscreen use, high rates of sunburning, and tanning bed use. Recommendations in the United States for improved sun protection and avoidance of tanning beds and sunburning, which began in the early 1990s, have been primarily unheeded. Nationally coordinated campaigns with strong policy components must be developed and sustained to prevent skin cancer in a new generation of children and adolescents.

Impact of skin cancer prevention on outdoor aquatics staff: the Pool Cool program in Hawaii and Massachusetts

BACKGROUND

Aquatic staff, including lifeguards, are exposed to intense sunlight for many hours each day and are likely to be at a relatively high risk for developing skin cancer. However, no interventions have been specifically directed to staff at outdoor swimming pool sites.

METHODS

We conducted a randomized controlled trial among aquatic staff at 28 outdoor pool sites in Hawaii and Massachusetts. Intervention pools received sun protection education and control pools received education on child injury prevention. Staff in both arms received orientation sessions and led instruction during swim lessons. Analysis of covariance was used to compare and test for changes in outcome variables (sun protection habits and sunburning rates of aquatic staff) and pool protection policies. Surveys were completed at the beginning and end of the summer.

RESULTS

Surveys were completed by 220 aquatics staff at baseline; 194 surveys were completed at posttest. Compared with staff at control pools, sun protection policies (P < 0.04) and sunburning rates (P < 0.05) improved at sun protection pools from baseline to posttest. However, the difference in the mean score of all sun protection habits between the two study groups was nonsignificant.

CONCLUSION

The Pool Cool sun protection intervention had significant effects on lifeguards' sunburn rates and pool sun safety policies but did not improve reported sun protection behaviors. More intensive strategies may be needed to influence aquatics workers who have already begun to adopt skin cancer prevention practices.

Sun protection behaviors and stages of change for the primary prevention of skin cancers among beachgoers in southeastern New England

Sun exposure is the most important avoidable cause of skin cancers. We report characteristics of a representative sample (N = 2,324) of beachgoers in Southeastern New England during the summer of 1995. This sample was not employing adequate sun protection behaviors (83% did not often avoid the sun during midday and only 45% often used sunscreen). Important demographic and skin cancer risk factor differences in sun protective behaviors and stages of change for sun protection were found, especially differences based on age, gender, and degree of sun sensitivity. Consistent with previous research, increased age, female gender, and greater sun sensitivity were each independently associated with more sun protective behaviors. These findings underscore the need for interventions targeting high-risk populations, such as those receiving high-intensity sun exposures at the beach.

Mechanisms of sunscreen failure

Sunscreen is used as a primary strategy to prevent sunburn and later skin cancer. However, sunscreen use has paradoxically been associated with the increasing incidence of skin cancer. One explanation for this puzzling observation is sunscreen failure (sunburn in the setting of sunscreen). Our purpose was to evaluate mechanisms of sunscreen failure in a sunscreen-using population. We carried out an epidemiologic comparison of sunburned and nonsunburned beachgoers who used sunscreen. We found that men were less likely to use sunscreen than women (chi(2) = 11.3, df = 1, P = .001), and when it was used, men were less likely to apply sunscreen to all sunlight-exposed skin (chi(2) = 18.4, df = 1, P = .0001). Swimmers who used sunscreen were significantly more likely to be sunburned compared with nonswimming sunscreen users (Fisher exact test, df = 1). Sunscreen may fail to prevent sunburn if it is washed off during swimming or if it is not applied to all exposed skin. Epidemiologic studies that link sunscreen use to skin cancer should evaluate whether sunburn occurred in this setting.

Sun protection practices in preadolescents and adolescents: a school-based survey of almost 25,000 Connecticut schoolchildren

Sun protection practices in children and adolescents fall well below national recommendations. We present the results of a survey of sun protection use and other health-related behaviors in a sample of Connecticut Caucasian students aged 9 through 18 years (N = 24,645). Our objectives were to estimate the prevalence of sun protection use and to evaluate the relationship between sun protection use and health-risk behaviors and attitudes about appearance. We present data from 1988 through 1995 from the Connecticut Health Check, a health risk appraisal survey sponsored by the Connecticut Department of Public Health. Students enrolled in public and private elementary junior as well as senior high schools took the self-administered anonymous survey, which included multiple-choice questions about use of sun protection, cigarettes, and alcohol and about body image and self-esteem. We report prevalence proportions for use of sun protection by demographic features. We compared the proportion of students in 3 categories of outcome (always, sometimes, and never use sun protection) who reported various health-risk behaviors. Twenty percent of the sample reported always using sun protection; this is well below national goals set forth in the Healthy People 2000 recommendations. Sun protection use was inversely related to age and was higher among girls than boys at all ages. At all ages, students who did not use sun protection were more likely than those who did to report other health risk behaviors, such as use of cigarettes and alcohol. The data suggested that use of sun protection is associated with positive attitudes about appearance and self-image. Use of sun protection may be one component of an overall mode of health awareness and behavior. Programs promoting safe sun practices should target boys and be integrated into an overall campaign aimed at other risk-taking behaviors.

Predictors for cutaneous basal- and squamous-cell carcinoma among actinically damaged adults

Risk factors for non-melanoma skin cancer among populations with evidence of precursor damage are not well described. We examined and compared risk factors associated with the development of cutaneous basal-cell (BCC) or squamous-cell (SCC) carcinoma among a group of 918 adults with significant sun damage (> or = 10 clinically assessable actinic keratoses) but no prior history of skin cancer. These adults were participants in a 5-year skin chemoprevention trial between 1985 and 1992, who had been randomized to the placebo group and followed for occurrence of skin cancer. During the study, a total of 129 first SCC and 164 first BCC lesions were diagnosed. The overall BCC and SCC incidence rates for this group of men and women, mean age 61 years, were 4,106 and 3,198 per 100,000 person-years, respectively. Different constitutional and exposure factors were independently associated with BCC compared to SCC. Only increased age independently predicted BCC occurrence among this population. In contrast, older age along with male gender, natural red hair color and adult residence in Arizona for 10 or more years independently predicted SCC occurrence. The substantial incidence of skin cancer found among this population confirms the need for active dermatological monitoring among individuals with multiple visible actinic lesions.

A national survey of sun safety activities at U.S. zoos

Skin cancer incidence in the United States has increased. Exposure to ultraviolet radiation (UVR) is a major risk factor for skin cancer. Every year, millions of children with their families visit outdoor leisure facilities such as zoos where overexposure to UVR may occur. This study was conducted to assess the proportion of U.S. zoos that provided sun safety activities during the summer of 1998 and their willingness to incorporate skin cancer prevention strategies at their facility in the future. A 56 item self-administered questionnaire was mailed to 140 zoos accredited by the American Zoo and Aquarium Association. A follow-up telephone survey was also conducted with 33 mail non-respondents. The response rate was 97% (N = 136). Results revealed that in the summer of 1998, only 5% of zoos provided sun safety recommendations to visitors and 25% of zoos provided recommendations to their employees. The recommendations made most often to visitors and employees were to use sunscreen and wear protective clothing. Eighty-five percent of zoos indicated interest in providing sun safety activities at their facilities in the future. The next step will be to design environmentally appropriate sun safety programs for zoos and to encourage zoos to implement these programs.

Predictors of the use of sunscreen in dermatological patients in Central Europe

BACKGROUND

There is mounting evidence that sun exposure is a cause of skin cancer. Therefore, the focus of skin cancer prevention is on sun protection. The present study investigated the use of sunscreens in a sample from the adult Central European population.

METHODS

As part of a case-control study of cutaneous melanoma, a total of 498 controls with classical dermatological disorders were selected from hospitals in Central Europe. All people underwent whole-body skin examinations and were interviewed using a standardized questionnaire.

RESULTS

Overall, 40.8% of the people never used sunscreen and of the 281 persons who used sunscreen, 41.5% applied it only once per sun bath. Persons who did not use sunscreen tended to be older (P<0.0001) and of male gender (P = 0.0004). Young people, women, and people who expressed a positive attitude to the sun spent more time in the sun and were more likely to apply sunscreens. People who worked almost always outdoors had a six times increased odds ratio of not using sunscreens (P<0.0001) compared to people who worked always indoors.

CONCLUSIONS

Men, older people, and outdoor workers should be targeted in health education campaigns. On the other hand, people who apply sunscreen as a means of sun protection should be advised about adequate usage.

Use of sunscreen in health care professionals. The health belief model

The purpose of this study was to examine the relationship among perceived susceptibility, demographic variables, and use of sunscreen in health care providers, using the Health Belief Model Questionnaire. The sample consisted of 90 participants from the Southeast, ages 24 to 60 years. This sample included nurses, pharmacists, psychologists, nurse practitioners, and physicians. Demographics revealed that 63% had postgraduate or professional degrees, 91% were white, 88% were women, 4% had a family history of skin cancer, and 4% had a personal history of skin cancer. Participants at actual high risk and those at actual low risk reported appropriate perceived susceptibility scores. However, those whose actual risk was average, perceived their risk to be low. There was no significant relationship found between actual risk of developing skin cancer and use of sunscreen. There was a significant relationship between age and perceived susceptibility to skin cancer. The older the subject, the higher the perceived susceptibility. Health care providers have the ability to influence individuals to use sunscreen. Accurately perceived susceptibility to skin cancer will increase the likelihood of health care providers recommending sunscreen to their patients.

Cancer surveillance series: changing patterns of cutaneous malignant melanoma mortality rates among whites in the United States

BACKGROUND

Mortality from melanoma among whites is still increasing in the United States. In this study, we describe the changing patterns of melanoma mortality rates among whites by demographic factors and geography and further assess the relationship between the geographic patterns and the UV radiation (UV-B) level.

METHODS

Age-adjusted incidence and mortality rates were computed by use of the 1970 U.S. population standard. Annual percent changes of mortality were estimated by fitting regression lines to the logarithm of rates. The relationships between melanoma mortality rates and UV-B level over time were assessed by weighted regressions. All statistical tests were two-sided.

RESULTS

From 1950-1954 through 1990-1994, melanoma mortality rates increased by 191% and 84% among males and females, respectively. Mortality rates peaked in the 1930 through 1950 birth cohorts for females and in the 1935 through 1950 birth cohorts for males. In the 1950 through 1969 study period, melanoma mortality rates showed a strong North-South gradient, but the gradient weakened in recent periods. The absolute change in mortality for a 10% increase in UV-B among females decreased from 0.08 additional deaths per 100 000 person-years in 1950-1959 to 0.01 additional deaths in 1990-1995. In contrast, the absolute change in mortality among males showed little change over time; additional deaths increased from 0.11 to 0.12 per 100 000 person-years.

CONCLUSIONS

Melanoma mortality in the United States reflects the complex interplay of UV radiation levels in each geographic region, the sun-protection behaviors of each generation of males and females in childhood and adulthood, the geographic mobility of the population, and the risk awareness and early detection.

Photoprotection

Protection from solar ultraviolet radiation is discussed. Methods of protection include avoiding outdoor activities during times of greatest ultraviolet radiation insolation, seeking shade while outdoors, and wearing appropriate clothing. Sunscreens are reviewed, including newer compounds that may also offer photoprotection.

Sunscreen use and duration of sun exposure: a double-blind, randomized trial

BACKGROUND

In epidemiologic studies, sunscreen use is associated with increased risk of cutaneous melanoma, basal cell skin cancer, and higher numbers of nevi. It has been proposed that sunscreens may encourage prolonged sun exposure because they delay sunburn occurrence. We examined whether, under habitual conditions of sunscreen use, the sun-protection factor (SPF) had an influence on sun-exposure duration.

METHODS

Before the 1997 summer holidays, we randomly assigned 87 French and Swiss participants who were 18-24 years of age to receive an SPF 10 or an SPF 30 sunscreen. Neither medical personnel nor study participants were aware of their sunscreen assignment. Participants were asked to complete daily records of their sun exposure. To avoid influencing the recreational sun-exposure habits of the study participants, no recommendation was made about sun exposure or sun protection. Furthermore, participants were told that the trial end point was the number of pigmented skin lesions before and after the holidays. One subject was lost to follow-up. All statistical tests were two-sided.

RESULTS

The SPF 10 (n = 44) and SPF 30 (n = 42) groups had equivalent mean holiday durations (19.4 days versus 20.2 days) and mean quantities of sunscreen used (72.3 g versus 71.6 g). The mean cumulative sun exposures for the two groups were 58.2 hours and 72.6 hours, respectively (P =.011). The mean daily durations of sunbathing were 2.6 and 3.1 hours, respectively (P =.0013), and, for outdoor activities, they were 3.6 and 3.8 hours, respectively (P =.62). There was no difference in sunburn experience between the two groups.

CONCLUSIONS

Use of higher SPF sunscreen seems to increase the duration of recreational sun exposure of young white Europeans.

Sun avoidance practices among non-Hispanic white Californians

This study measures self-reported sun avoidance practices, use of protective clothing, and use of sunscreen among 4,749 non-Hispanic white adults living in households in California. Data are from the California Behavioral Risk Factor Survey, a population-based telephone survey of health behaviors and attitudes. The average respondent spent at least 15 minutes in the sun on 21.4 days out of the last 30 days. Regular use of protective clothing was reported by 30.7%, regular use of sunscreen by 22.2%, and regular sun avoidance by 17.1% of the respondents. Results varied by month, gender, skin tone, age, education, and presence of children in the household. Health strategies should target younger adults (especially men), households with children and adults with less than a high school education. Because of relatively low rates of sun avoidance behaviors overall, a general population campaign also is warranted.