Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: Review from national surveys and case studies of 3 states

Patient demographic characteristics and risk factors associated with sun protection behaviours in specialist melanoma clinics

OBJECTIVE

We investigated the association between sun protection behaviours and demographic and melanoma risk characteristics of patients attending Australian melanoma specialist clinics. This may assist in targeting and tailoring melanoma prevention patient education for people at high-risk and specific population subgroups.

METHODS

A cross-sectional analysis of questionnaire data collected from participants attending the dermatology clinics at two major melanoma centres in Sydney, Australia between February 2021 and September 2023. The primary outcome was Sun Protection Habits (SPH) index (a summary score measured as habitual past month use of sunscreen, hats, sunglasses, a shirt with sleeves that covers the shoulders, limiting midday sun exposure and seeking shade, using a Likert scale). The primary analysis considered the SPH index and its component items scored as continuous.

RESULTS

Data from 883 people were analysed. Factors associated with less frequent sun protection behaviours overall included male gender, no personal history of melanoma, lower perceived risk, lower calculated 10-year risk of developing melanoma, and no private health insurance. People aged >61 years reported lower use of sunscreen but higher use of hats and sleeved-shirts compared with people in the younger age group. There was no difference in overall sun protection behaviours according to family history of melanoma, country of birth or by lifetime melanoma risk among people without a personal history of melanoma.

CONCLUSIONS

These findings highlight the potential for targeting high-risk individuals with less frequent use of sun protection for patient education, public health messaging and ultimately improving sun protection behaviours.

Biomarkers in Cutaneous Keratinocyte Carcinomas

Skin cancer is the most common cancer type in the USA, with over five million annually treated cases and one in five Americans predicted to develop the disease by the age of 70. Skin cancer can be classified as melanoma or non-melanoma (NMSC), the latter including basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC). Development of BCC and SCC is impacted by environmental, behavioral, and genetic risk factors and the incidence is on the rise, with the associated number of deaths surpassing those caused by melanoma, according to recent reports. Substantial morbidity is related to both BCC and SCC, including disfigurement, loss of function, and chronic pain, driving high treatment costs, and representing a heavy financial burden to patients and healthcare systems worldwide. Clinical presentations of BCC and SCC can be diverse, sometimes carrying considerable phenotypic similarities to benign lesions, and underscoring the need for the development of disease-specific biomarkers. Skin biomarker profiling plays an important role in deeper disease understanding, as well as in guiding clinical diagnosis and patient management, prompting the use of both invasive and non-invasive tools to evaluate specific biomarkers. In this work, we review the known and emerging biomarkers of BCC and SCC, with a focus on molecular and histologic biomarkers relevant for aspects of patient management, including prevention/risk assessments, tumor diagnosis, and therapy selection.

Factors Influencing Margin Clearance and the Number of Stages of Mohs Micrographic Surgery in Basal Cell Carcinoma: A Retrospective Chart Review

How patient and tumor factors influence clearance margins and the number of Mohs Micrographic Surgery (MMS) stages when treating basal cell carcinoma (BCC) remains widely uncharacterized. It is important to elucidate these relationships, as surgical outcomes may be compared nationally between colleagues. Our objective is to evaluate the relationships between defect size and patient demographics, as well as between BCC subtypes and the number of MMS stages. Our second objective is to compare practice patterns and characteristics of patients requiring MMS at academic centers and private practices. A retrospective chart review was performed using data collected at academic centers (2015-2018) and private practices (2011-2018) of BCC patients older than 18 years old who underwent MMS. In total, 7651 patients with BCC requiring MMS were identified. Academic center adjusted analyses demonstrated clearance margins 0.1 mm higher for every year's increase in age (p < 0.0001) and 0.25 increase in MMS stages for high-risk BCC (p < 0.0001). Private practice adjusted analyses demonstrated clearance margins 0.04 mm higher for every year's increase in age (p < 0.0001). Clearance margins correlate with older age, and additional MMS stages correlate with high-risk BCC, suggesting the role patient and tumor factors may play in predicting tumor clearance and MMS stages.

Associations of Dietary Factors with Cutaneous Melanoma: A Case-Control Study in Greece with Literature Review

INTRODUCTION

It has been postulated that nutrition may influence the risk for cutaneous melanoma (CM); therefore, we aimed to assess the associations of food groups and individual nutrient intakes with CM in a Greek population.

METHODS

In this case-control study, 151 patients with histologically confirmed CM, newly diagnosed and treated in the Oncology Department of the "Laikon" University Hospital (Athens, Greece), and 151 age- and sex-matched healthy individuals residing in the Athens metropolitan area, recruited among participants for routine health examinations, were included. All participants completed a questionnaire comprising anthropometric measurements, sociodemographic, lifestyle, and health-related variables. A validated, semiquantitative food frequency questionnaire was used to assess average consumption of 136 food items during the 12 months preceding the onset of disease. Multivariate conditional regression models were used to derive odds ratios (ORs) with 95% confidence intervals (95% CI) regarding the association of nine food groups and seven macronutrients with CM.

RESULTS

Statistically significant positive associations with CM were found with higher energy intake (OR: 1.67, 95% CI: 1.22-2.30) and intake of saturated fatty acids (OR: 2.28, 95% CI: 1.00-5.28), after adjusting for sun sensitivity, major depression history, and alcohol intake. Inverse associations with higher intake of milk and dairy products (OR: 0.65, 95% CI: 0.48-0.88), fruits (OR: 0.68, 95% CI: 0.51-0.90), added lipids (OR: 0.65, 95% CI: 0.47-0.91), and sugars and syrups (OR: 0.70, 95% CI: 0.53-0.93) were also observed.

CONCLUSIONS

Beyond intrinsic risk factors, our results support associations of CM with multiple food groups and nutrients; if confirmed by prospective studies, these findings can add further knowledge about this fatal cancer.

#4Corners4Health Social Media Cancer Prevention Campaign for Emerging Adults: Protocol for a Randomized Stepped-Wedge Trial

BACKGROUND

Many emerging adults (EAs) are prone to making unhealthy choices, which increase their risk of premature cancer morbidity and mortality. In the era of social media, rigorous research on interventions to promote health behaviors for cancer risk reduction among EAs delivered over social media is limited. Cancer prevention information and recommendations may reach EAs more effectively over social media than in settings such as health care, schools, and workplaces, particularly for EAs residing in rural areas.

OBJECTIVE

This pragmatic randomized trial aims to evaluate a multirisk factor intervention using a social media campaign designed with community advisers aimed at decreasing cancer risk factors among EAs. The trial will target EAs from diverse backgrounds living in rural counties in the Four Corners states of Arizona, Colorado, New Mexico, and Utah.

METHODS

We will recruit a sample of EAs (n=1000) aged 18 to 26 years residing in rural counties (Rural-Urban Continuum Codes 4 to 9) in the Four Corners states from the Qualtrics' research panel and enroll them in a randomized stepped-wedge, quasi-experimental design. The inclusion criteria include English proficiency and regular social media engagement. A social media intervention will promote guideline-related goals for increased physical activity, healthy eating, and human papillomavirus vaccination and reduced nicotine product use, alcohol intake, and solar UV radiation exposure. Campaign posts will cover digital and media literacy skills, responses to misinformation, communication with family and friends, and referral to community resources. The intervention will be delivered over 12 months in Facebook private groups and will be guided by advisory groups of community stakeholders and EAs and focus groups with EAs. The EAs will complete assessments at baseline and at 12, 26, 39, 52, and 104 weeks after randomization. Assessments will measure 6 cancer risk behaviors, theoretical mediators, and participants' engagement with the social media campaign.

RESULTS

The trial is in its start-up phase. It is being led by a steering committee. Team members are working in 3 subcommittees to optimize community engagement, the social media intervention, and the measures to be used. The Stakeholder Organization Advisory Board and Emerging Adult Advisory Board were formed and provided initial input on the priority of cancer risk factors to target, social media use by EAs, and community resources available. A framework for the social media campaign with topics, format, and theoretical mediators has been created, along with protocols for campaign management.

CONCLUSIONS

Social media can be used as a platform to counter misinformation and improve reliable health information to promote health behaviors that reduce cancer risks among EAs. Because of the popularity of web-based information sources among EAs, an innovative, multirisk factor intervention using a social media campaign has the potential to reduce their cancer risk behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05618158; https://classic.clinicaltrials.gov/ct2/show/NCT05618158.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50392.

Ethnic and Gender Differences in Sun-Related Cognitions Among College Students: Implications for Intervention

BACKGROUND

Skin cancer incidence and prognosis vary by ethnicity and gender, and previous studies demonstrate ethnic and gender differences in sun-related cognitions and behaviors that contribute to this disease. The current study sought to inform skin cancer interventions tailored to specific demographic groups of college students. The study applied the prototype willingness model (PWM) to examine how unique combinations of ethnic and gender identities influence sun-related cognitions.

METHOD

Using data from a survey of 262 college students, the study tested whether self-reported sun-related cognitions were different for White women, Hispanic women, White men, and Hispanic men. Path modeling was also used to identify which PWM cognitions (e.g., prototypes, norms) were the strongest predictors of risk and protection intentions and willingness in each demographic group.

RESULTS

Several differences in sun-related cognitions and PWM pathways emerged across groups, emphasizing the need for tailored skin cancer education and interventions. Results suggest that, for White women, interventions should primarily focus on creating less favorable attitudes toward being tan.

CONCLUSION

Interventions for Hispanic women may instead benefit from manipulating perceived similarity to sun-related prototypes, encouraging closer personal identification with images of women who protect their skin and encouraging less identification with images of women who tan. For White men, skin cancer interventions may focus on creating more favorable images of men who protect their skin from the sun. Lastly, interventions for Hispanic men should increase perceived vulnerability for skin cancer.

Causal associations between modifiable risk factors and isolated REM sleep behavior disorder: a mendelian randomization study

Objectives

This Mendelian randomization (MR) study identified modifiable risk factors for isolated rapid eye movement sleep behavior disorder (iRBD).

Methods

Genome-wide association study (GWAS) datasets for 29 modifiable risk factors for iRBD in discovery and replication stages were used. GWAS data for iRBD cases were obtained from the International RBD Study Group. The inverse variance weighted (IVW) method was primarily employed to explore causality, with supplementary analyses used to verify the robustness of IVW findings. Co-localization analysis further substantiated causal associations identified via MR. Genetic correlations between mental illness and iRBD were identified using trait covariance, linkage disequilibrium score regression, and co-localization analyses.

Results

Our study revealed causal associations between sun exposure-related factors and iRBD. Utilizing sun protection (odds ratio [OR] = 0.31 [0.14, 0.69], p = 0.004), ease of sunburn (OR = 0.70 [0.57, 0.87], p = 0.001), childhood sunburn occasions (OR = 0.58 [0.39, 0.87], p = 0.008), and phototoxic dermatitis (OR = 0.78 [0.66, 0.92], p = 0.003) decreased iRBD risk. Conversely, a deep skin color increased risk (OR = 1.42 [1.04, 1.93], p = 0.026). Smoking, alcohol consumption, low education levels, and mental illness were not risk factors for iRBD. Anxiety disorders and iRBD were genetically correlated.

Conclusion

Our study does not corroborate previous findings that identified smoking, alcohol use, low education, and mental illness as risk factors for iRBD. Moreover, we found that excessive sun exposure elevates iRBD risk. These findings offer new insights for screening high-risk populations and devising preventive measures.

Sun protection practices in India: Preliminary findings from a nationally representative sample

Sun safety research has mainly been conducted in the West, whereas little is known about sun protection practices in India. Using a survey design with a representative sample, we aimed to understand the frequency of sun protection practices in India. We also examined associations between demographic covariates and sun safe behaviours. We surveyed a representative sample (N = 1560) from the Indian population in November 2022. The study variables included sun safe behaviours, sunburn experience, demographic information, and skin tone. We employed descriptive and regression analyses to examine the prevalence of behaviours and their associations. To mitigate potential sampling biases, we applied poststratification weights in the analyses. More than half of the participants (64.2%) routinely performed at least one sun safe behaviour, with only 4.9% of the sample reporting no engagement with sun safe behaviours in the last 12 months. Physical protection (e.g., long sleeves, shade/umbrella) were more common than sunscreen use. Regression analysis showed that higher subjective social status, being younger, and living in one of the Eastern Indian states were the strongest predictors of sun protection practices. Our findings fill an important knowledge gap in global sun safe research, highlighting the urgent need for public sun safety education. Scalable and targeted interventions are needed to promote sun safety awareness and practices among people.

Sun protection use and habits in the LGBTQI+ community in Lebanon: A cross sectional study

BACKGROUND

Sun exposure is an extrinsic risk factor for skin aging, wrinkle formation, and the development of skin cancer, namely melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). Sun protection measures have emerged as an important means of preventing these harmful effects. Studies have shown that sexual minority men have a greater prevalence of skin cancer than heterosexual men.

AIMS

There is limited research investigating the reasons behind this risk of skin cancer development. This is especially important because identifying preventable risk factors, like those pertaining to sun exposure behaviors, can be targeted in the fight against skin cancer and help establish screening tools and preventive interventions for the SGM community. This study focused on members of the SGM community and demonstrated their tendency not to use sun-protective measures, as well as their deficits in knowledge of skin cancer prevention.

MATERIALS AND METHODS

This study is a cross-sectional study that investigates sun protection practices and trends among adults in Lebanon's SGM community using a survey. It includes adults aged 18-80 that were recruited from the dermatology clinics at AUBMC as well as LGBTQ+ organizations Helm and SIDC.

RESULTS

A total of 129 participants took part in the study and completed the survey. Reasons for tanning varied among our participants: tanning to get a color (13.1%), tanning to get vitamin D (4.6%), tanning socially (6.9%), and tanning for mood elevation (0.8%). No significant association was found between sexual orientation and SPF use (p = 0.167). No significant association was found between sexual orientation and tanning frequency during summer (p-value: 0.231). Similarly, no significant association was noted between sexual orientation and tanning bed use (0.951). No significant association was noted between the type of job and SPF use (p = 0.601). Despite no significance between SPF use and the highest educational degree attained (p = 0.070), the tendency to use SPF increased with higher levels of education. Moreover, awareness of sun-induced skin cancer did not significantly affect SPF use (p = 0.067). However, a significant association was found between the information source for skin cancer and SPF use (p < 0.001) where participants receiving information from dermatologists displayed notably higher SPF use (72.2%), compared to those obtaining information from media (18.2%) or family and friends (5.3%).

DISCUSSION

Surveying the perception of the Lebanese SGM community towards sun damage and their adaptive practices to prevent it can help implement and gear a nation-wide campaign to spread proper awareness about this subject. Studying their behavioral tendencies for not using sunscreen can help overcome this contributing risk factor for skin cancers.

CONCLUSION

Future investigations have yet to identify confounding variables contributing to higher levels of skin cancers in this population.

Melanoma literacy among the general population of three western US states

Melanoma is a significant cause of cancer death, despite being detectable without specialized or invasive technologies. Understanding barriers to preventive behaviors such as skin self-examination (SSE) could help to define interventions for increasing the frequency of early detection. To determine melanoma knowledge and beliefs across three high-incidence US states, 15,000 surveys were sent to a population-representative sample. We aimed to assess (1) melanoma literacy (i.e., knowledge about melanoma risks, attitudes, and preventive behaviors) and (2) self-reported SSE and its association with melanoma literacy, self-efficacy, and belief in the benefits of SSE. Of 2326 respondents, only 21.2% provided responses indicating high knowledge of melanoma, and 62.8% reported performing an SSE at any time in their lives. Only 38.3% and 7.3% reported being "fairly" or "very" confident about doing SSE, respectively. SSE performance among respondents was most strongly associated with higher melanoma knowledge, higher self-efficacy, and personal history of melanoma. Melanoma literacy among survey respondents was modest, with greater literacy associated with a higher likelihood of reported preventive behavior. This assessment establishes a baseline and provides guidance for public health campaigns designed to increase prevention and early detection of this lethal cancer.

Reinforcing Photoprotection for Skin of Color: A Narrative Review

Skin of color (SOC) is characterized by increased tendency for tanning and decreased likelihood of sunburns due to the attenuation of sunlight by epidermal melanin. Although this contributes to the decreased incidence of skin cancer among SOC populations, individuals with SOC remain susceptible to various health consequences associated with sun exposure, including non-melanoma skin cancer, photoaging, pigmentary disorders, and photodermatoses - many of which not only present differently, but also disproportionately affect SOC. Prior epidemiological studies have found lower prevalence of sun protection behaviors among individuals with SOC, particularly in sunscreen use, signifying an unmet area for improvement in the prevention of sun-induced dermatologic conditions in these populations. The objective of this narrative review was to summarize the biology and health consequences of sun exposure in SOC, as well as cognitive and behavioral factors that affect the practice of photoprotection behaviors in SOC populations. We also review prior interventions that have been used to enhance photoprotection knowledge and behaviors among individuals with SOC, either in racially and ethnically diverse communities or within specific SOC populations.

Current practice and beliefs of parents toward sunscreen use for their children: A cross-sectional study

Parents are generally influencing the sun protection behaviors of their children, including sunscreen use. In Saudi Arabia, sunscreen use was estimated in adults but not children. The objective was to estimate the prevalence and predictors of sunscreen use among parents and their children. An observational cross-sectional study was conducted in April 2022. Parents who were visiting outpatient clinics at a university hospital in Al-Kharj city, Saudi Arabia, were invited to complete an online questionnaire. A total of 266 participants were included in the final analysis. The mean age of parents was 39.0 ± 8.9 years, and the mean age of children was 8.2 ± 3.2 years. The prevalence of sunscreen use was 38.7% in parents and 24.1% in their children. Females had higher sunscreen use than males in both parents (49.7% versus 7.2%, p < 0.001) and in children (31.9% versus 18.3%, p = 0.011). The most frequent sunburn protection measures practiced by children were wearing long-sleeved clothes (77.0%), sitting in the shade (70.6%), and wearing hats (39.2%). In multivariable analysis, predictors of sunscreen use in parents included female sex, history of sunburn, and sunscreen use by children. Independent predictors of sunscreen use in children included a history of sunburn, wearing hats, and practicing other sunburn protection measures on risky occasions, and sunscreen use in parents. Sunscreen use in parents and children in Saudi Arabia is still inadequate or limited. This calls for community/school intervention programs using educational activities and multimedia promotion. Further studies are needed.

Sun protective behaviors among adolescents and young adults in the United States

PURPOSE

We described sun protective behaviors in adolescents and young adults (AYA) compared to older adults.

METHODS

We used data from the 2013-2018 National Health and Nutrition Examination Survey, a nationally representative samples of the civilian, noninstitutionalized US population (10,710 respondents aged between 20 and 59 and without a history of skin cancer diagnoses). The primary exposure for the study was age group: aged 20-39 defined as AYA and aged 40-59 as adults. The outcome variable was sun protective behaviors: stay in the shade, wear a long-sleeved shirt, use sunscreen, at least one of the three; and all three measures. Multivariable logistic regression models were used to assess association between age group and sun protective behaviors adjusting for sociodemographic factors.

RESULTS

Overall, 51.3% of respondents were AYA, 76.1% reported staying in the shade, 50.9% using sunscreen, 33.3% wearing long-sleeved clothes, 88.1% engaging in one of the three behaviors, and 17.1% engaging in all three behaviors. In the adjusted models, the odds of engaging in all three behaviors among AYAs was 28% (aOR: 0.72, 95% CI: 0.62-0.83) lower than adult respondents. Compared to adults, AYAs were 22% less likely to wear long sleeved clothes (aOR: 0.78, 95% CI: 0.70-0.87). There were no significant differences in the odds of engaging in at least one sun protective behavior, using sunscreen, and staying in the shade between AYAs and adults.

CONCLUSIONS

More targeted interventions need to be implemented to decrease the risk of skin cancer in the AYA population.

Patterns of Sun Protection Behaviours among Australian Adolescents and Adults over a Six-Year Period

The major cause for skin cancer is the excessive and unprotected exposure to ultraviolet radiation (UVR), which can be prevented by engaging in sun protection behaviours. As longitudinal studies on both adolescents' and adults' performances of sun protection behaviours are limited, the current study aimed to investigate changes in sun protection in these population segments in Western Australia, a region with high annual UVR. During six summer seasons (2015/16 to 2020/21), cross-sectional surveys were conducted among 1806 adolescents (14 to 17 years old) and 1808 adults (18-45 years old), investigating the frequency of five sun protection behaviours (wearing clothing, applying sunscreen, wearing a hat, wearing sunglasses, and seeking shade) and sun avoidance (staying indoors). Over the six-year period, staying indoors increased in both groups. Among adolescents, a decrease in wearing clothing and sunglasses and an increase in seeking shade was demonstrated, and hat and sunscreen use remained relatively stable. Among adults, an increase in sunscreen use was shown, whereas all other sun-related behaviours remained consistent over the six-year period. The results from this study can provide directions for health communications focusing on improving sun protection behaviours among both adolescent and adult populations.

A systematic review on traditional, ayurvedic, and herbal approaches to treat solar erythema

Solar erythema is a kind of radiation burn that strikes living tissue, such as skin, that arises from overexposure to UV radiation often from the sun. Ordinary symptoms of solar erythema include reddish skin, specifically warm to touch, overall tiredness, hurting, and mild whirl. Sunscreen contains SPF value, which measures how much ultraviolet radiation is needed to cause sunburn on sunscreen-applied skin, which is proportional to the quantity of solar energy needed to cause sunburn on unprotected skin. Between 30 and 50 SPF value is sufficient to protect from sunburn, especially for the people who are more sensitive to sunburn. Sunscreen also protects from sun damage including dark spots and discoloration and helps to keep skin smooth, spotless, and more even. Chemical-based sunscreen is widely used because it effectively protects the skin from sun damage, but it clogs pores and can be problematic for sensitive skin as it can cause itching or stinging of the skin and pus in the hair follicles. On the other hand, herbal sunscreen absorbs light preferentially over the range of 280-320 mm without causing any harm to the skin and eyes. Ayurveda rejuvenates dull skin by regaining the skin's natural glow and radiance. This review concludes the damaging and harmful effects of UV rays, along with various traditional, ayurvedic, and herbal approaches to treat solar erythema naturally.

Prevalence and correlates of skin examination among ethnically diverse young adult survivors of childhood cancer

BACKGROUND

Skin cancer is the most common secondary malignancy among young adult childhood cancer survivors (YA-CCS). Skin examination to detect skin cancer early (including melanoma as well as basal or squamous cell skin cancers), both physician-based (PSE) and self-skin exam (SSE), is recommended, particularly for radiotherapy-exposed YA-CCS who are at high risk of developing skin cancer.

METHODS

Awareness and prevalence of skin examination and demographic, clinical, and healthcare correlates were examined in a population-based sample of YA-CCS with diverse cancer types excluding melanoma. Descriptive frequencies and logistic regression models were conducted using sample weights to correct for non-response bias with PSE, SSE and adherence to both as outcomes.

RESULTS

The sample comprised 1064 participants with 53% Latino. Eight percent of participants were aware of the need for skin examination; 9% reported receipt of PSE within past 2 years; 35% reported regular SSE; and 6% were adherent to both. Among the radiotherapy-treated, 10% were aware of the need for skin examination, 10% reported recent PSE; 38% reported regular SSE; and 8% were adherent to both. Healthcare and clinical factors including healthcare self-efficacy, engagement in cancer-related follow-up care, greater treatment intensity and greater number of treatment-related late effects were positively associated with PSE and SSE. Latino YA-CCS were less likely to engage in PSE and SSE.

CONCLUSION(S)

Adherence to recommended screening for skin cancer was low in this at-risk population, notably for YA-CCS exposed to radiotherapy. The development of effective strategies to expand skin cancer screening is needed in this at-risk population.

Association of Sun Safety Behaviors and Barriers with Sunburn History in College Students in a Region with High UV Exposure

Over five million cases of skin cancer are diagnosed each year in the United States with melanoma the third most common cancer in young adults. While publications have shown that sunburns increase the risk of developing melanoma throughout the lifetime including in adolescence and adulthood showing the importance of altering sun exposing behaviors throughout the lifetime, use of sun protection in college students remails low. In Fall 2019, an online survey of undergraduate students living on campus at a large southwestern university was conducted to determine the frequency of recent sunburns as well as sun protective behaviors and perceived knowledge of and barriers to sun protection. Associations between knowledge, behaviors, and barriers with self-reported sunburn were evaluated using logistic regression. Over 46% of 458 students reported at least one sunburn in the past three months and 21% reported having multiple sunburns in that period. Furthermore, 53% reported that they intentionally tanned their skin outdoors occasionally or more frequently, while 6.4% reported using an indoor tanning bed occasionally or more. Adjusted for skin sensitivity, recent sunburn history was associated with higher tanning activity scores and with high agreement that tanning was attractive (p < 0.01). This information can inform a more targeted series of intervention programming on the university campus.

Skin tone preferences and their influence on skin care behaviors

Knowledge regarding skin tone preferences and their influence on skincare behaviors among people of color is limited. The objective of this study was to determine whether there is a difference between ideal and actual skin tone among people of color and whether this difference is associated with tanning and sunscreen use. This was a one-time, voluntary, anonymous, electronic survey designed in REDCap and delivered through ResearchMatch, a national electronic, recruitment tool. Eligible participants were at least 18 years old and self-identified as Black, Asian, Latinx, American Indian/Alaskan Native or Mixed Race. In total, 548 completed survey results were analyzed using SAS. Only the Latinx population was found to have a significant preference for tanner skin (p < 0.05). The Latinx population had significantly more subjects that participated in outdoor tanning than both the Black (p < 0.0001) and Asian population (p < 0.05). Latinx participants who indicated a preference for tanner skin were 2.8 times more likely to never use sunscreen than those without this preference (OR = 2.821, CI = 1.029-7.732, p < 0.05). Our findings have implications for how dermatologists screen, treat, and educate Latinx and skin of color populations.

'I had a bigger cancer risk than I thought…': The experience of receiving personalized risk information as part of a skin cancer prevention intervention in the college setting

BACKGROUND

Diagnoses of both melanoma and nonmelanoma skin cancers are becoming increasingly common among young adults. Interventions in this population are a priority because they do not consistently follow skin cancer prevention recommendations.

OBJECTIVES

The goal of the current study was to examine college students' perspectives on and experience with receiving a skin cancer prevention intervention that provided personalized skin cancer risk feedback in the form of an ultraviolet (UV) photograph, the results of genetic testing for common skin cancer risk variants, and/or general skin cancer prevention education.

METHODS

Qualitative interviews were conducted with 38 college students who received a skin cancer prevention intervention. The interview covered students' feelings about their personal skin cancer risk information, the impact of the intervention on their skin cancer risk perceptions, actions or intentions to act with regard to their sun protection practices and feedback for improvement of the intervention content or delivery.

RESULTS

Participants reported that different intervention components contributed to increased awareness of their sun protection behaviours, shifts in cognitions about and motivation to implement sun protection strategies and reported changes to their skin cancer prevention strategies.

CONCLUSION

Our findings indicate that college students are interested in and responsive to these types of multicomponent skin cancer preventive interventions. Further, students demonstrate some motivation and intentionality toward changing their skin cancer risk behaviour in the short term.

PATIENT OR PUBLIC CONTRIBUTION

Participants involved in this study were members of the public (undergraduate students) who were involved in a skin cancer prevention intervention, then participated in semistructured interviews, which provided the data analysed for this study.

Outdoor activities and sunburn among urban and rural families in a Western region of the US: Implications for skin cancer prevention

Prevention of skin cancer involves decreasing exposure to ultraviolet radiation (UVR) and avoiding sunburn, especially early in life. Individuals living in urban versus rural areas, as defined by the Rural Urban Commuting Area (RUCA) code classification, have different risks for skin cancer, likely due to differing patterns of outdoor activities and preventive behaviors employed when outdoors. However, few studies have examined differences in outdoor activities between rural and urban individuals and examined this among both adults and children. This study compared the outdoor activities, sun protection strategies, tanning behaviors, and sunburn occurrence of adults and children (n = 97 dyads) in rural versus urban settings in a Western region of the United States. The relationships between outdoor activities and sunburn occurrence were examined in both groups. Analyses employed Barnard's Exact Test and logistic generalized estimating equations models. Individuals in rural and urban areas reported differences in sun protection strategies used, tanning behaviors, and outdoor activities. Individuals in urban areas more commonly reported use of certain forms of sun protection, such as sunscreen and shade, whereas long pants and skirt wearing were more common for children in rural areas. Individuals in rural areas were more likely than those in urban areas to engage in farm work, yard work, and youth sports. Gender differences in these outcomes were also identified. Skin cancer preventive interventions could be tailored for rural and urban families to target sun protection strategies to outdoor activities and to situations in which sunburns are likely to occur.

Skin Cancer Narratives on Instagram: Content Analysis

Background

Skin cancer is among the deadliest forms of cancer in the United States. The American Cancer Society reported that 3 million skin cancer cases could be avoided every year if individuals are more aware of the risk factors related to sun exposure and prevention. Social media platforms may serve as potential intervention modalities that can be used to raise public awareness of several diseases and health conditions, including skin cancer. Social media platforms are efficient, cost-effective tools for health-related content that can reach a broad number of individuals who are already using these spaces in their day-to-day personal lives. Instagram was launched in 2010, and it is now used by 1 billion users, of which 90% are under the age of 35 years. Despite previous research highlighting the potential of image-based platforms in skin cancer prevention and leveraging Instagram’s popularity among the priority population to raise awareness, there is still a lack of studies describing skin cancer–related content on Instagram.

Objective

This study aims to describe skin cancer–related content on Instagram, including the type of account; the characteristics of the content, such as the kind of media used; and the type of skin cancer discussed. This study also seeks to reveal content themes in terms of skin cancer risks, treatment, and prevention.

Methods

Through CrowdTangle, a Facebook-owned tool, we retrieved content from publicly available accounts on Instagram for the 30 days preceding May 14, 2021. Out of 2932 posts, we randomly selected 1000 posts for review. Of the 1000 posts, 592 (59.2%) met the following inclusion criteria: (1) content was focused on human skin cancer, (2) written in English language only, and (3) originated from the United States. Guided by previous research and through an iterative process, 2 undergraduate students independently coded the remaining posts. The 2 coders and a moderator met several times to refine the codebook.

Results

Of the 592 posts, profiles representing organizations (n=321, 54.2%) were slightly more common than individual accounts (n=256, 43.2%). The type of media included in the posts varied, with posts containing photos occurring more frequently (n=315, 53.2%) than posts containing infographics (n=233, 39.4%) or videos (n=85, 14.4%). Melanoma was the most mentioned type of skin cancer (n=252, 42.6%). Prevention methods (n=404, 68.2%) were discussed in Instagram posts more often than risk factors (n=271, 45.8%). Only 81 out of 592 (13.7%) posts provided a citation.

Conclusions

This study’s findings highlight the potential role of Instagram as a platform for improving awareness of skin cancer risks and the benefits of prevention practices. We believe that social media is the most promising venue for researchers and dermatologists to dedicate their efforts and presence that can widely reach the public to educate about skin cancer and empower prevention.

Environmental factors associated with juvenile idiopathic inflammatory myopathy clinical and serologic phenotypes

BACKGROUND

Environmental exposures have been associated with the juvenile idiopathic inflammatory myopathies (JIIM). We undertook a questionnaire-based study to evaluate patient-reported exposures as possible risk factors for JIIM.

FINDINGS

One-hundred-seven patients with JIIM were enrolled in a myositis natural history protocol and completed environmental questionnaires. Frequencies of exposures in clinical and myositis-specific autoantibody (MSA) groups were examined. Patients with juvenile dermatomyositis (JDM) and juvenile connective tissue myositis (JCTM) more frequently received an immunization within 1 year of diagnosis compared to juvenile polymyositis (57.5 and 71.4% vs 0.0%, p ≤ 0.017). JCTM patients were more often underweight at diagnosis relative to JDM patients (42.9% vs 7.0%, p = 0.002). MSA-negative patients more frequently had gastroenteritis within a year of diagnosis compared to patients with anti-MDA5 autoantibodies (28.6% vs 0.0%, p = 0.032). Heavy exercise was more frequent in MSA-negative and anti-MDA5 groups compared to the anti-TIF-1 autoantibody group (42.9 and 35.3% vs. 9.0%, p ≤ 0.047). Medications received within 1 year of diagnosis were more frequent in MSA-negative patients relative to those with anti-MDA5 autoantibodies (92.9% vs. 52.8% p = 0.045). Being breastfed > 6 months was more frequent in MSA-negative patients (88.9%) compared to anti-TIF-1 and anti-MDA5 autoantibody groups (41.2 and 28.6%, p ≤ 0.036).

CONCLUSIONS

Certain environmental exposures prior to diagnosis differed among clinical and serologic subgroups of JIIM, suggesting additional exposures to be explored as possible risk factors for JIIM phenotypes.

Photoprotection for Skin of Color

Photoprotection behaviors can mitigate skin damage caused by ultraviolet radiation, and common methods include seeking shade, avoiding sun exposure during peak daylight hours, wearing sun-protective clothing, applying sunscreen, and using sunglasses. While the role of sun protection in preventing sunburns, photoaging, and skin cancer is well established in fair-skinned populations, individuals with skin of color (SOC) are presumed to suffer fewer negative effects from solar radiation. Thus, the importance of photoprotection in this population is understudied and may be underestimated. In SOC populations, sun exposure is known to cause pigmentary disorders, photoaging, and basal cell carcinoma (BCC), highlighting the potential benefits of photoprotection. Although SOC populations tend to practice photoprotection by seeking shade and wearing sun-protective clothing, survey and interview-based studies have consistently found relatively low use of sunscreen among these populations. Common motivators for photoprotection in individuals with SOC include preventing sunburn and pigmentation, with the prevention of skin cancer being a less important reason. As a skin cancer risk behavior, indoor tanning is relatively rare in SOC populations, but its use may increase with acculturation to US norms. While more studies are necessary to clarify whether photoprotection behaviors may decrease skin cancer-related mortality in SOC populations, regular dermatologic care and counseling on photoprotection remain essential in patients with SOC for overall skin health.

Proof-of-Concept Feasibility Trial of a Dissonance-Based Sun Safety Intervention for Young Adult Tanners

BACKGROUND

Melanoma is the second most common cancer in young adults. Social media may be a means to conduct interventions to increase sun safety in young adults.

PURPOSE

We conducted a randomized proof-of-concept pilot trial to evaluate the feasibility and acceptability of a dissonance-based social media intervention designed to promote sun safety in young adult tanners.

METHODS

Young adult tanners (N = 66) were randomized into two 4-week interventions in which participants were incentivized to create content for a social media campaign on healthy skin or healthy lifestyle. Feasibility outcomes included retention, participation, acceptability, and contamination. We also examined the impact of participation on motivation to engage in the target health behaviors and outdoor tanning intentions.

RESULTS

Retention was 100%. Most Healthy Skin (88%) and Healthy Lifestyle participants (91%) created ≥1 post. Acceptability was high with 94% and 97% of participants in Healthy Skin and Healthy Lifestyle conditions, respectively, agreeing they would recommend the campaign to a friend. At 4 weeks, Healthy Skin participants reported greater declines in motivation to tan indoors (p = .0017) and outdoors (p = .0003), and greater increases in motivation to wear sunscreen (p = .0009) and protective clothing (p = .0342). Healthy Skin participants reported greater declines in intentions to tan outdoors in the next year (p = .0286).

CONCLUSIONS

A dissonance-based, social media sun safety intervention was feasible and acceptable. Future research should examine the efficacy and longer-term effects of this intervention in young adults at elevated risk for skin cancer.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03834974 https://clinicaltrials.gov/ct2/show/NCT03834974.

UV-Induced Skin Cancer Knowledge, Sun Exposure, and Tanning Behavior among University Students: Investigation of an Opportunity Sample of German University Students

Ultraviolet radiation (UVR) is the most important risk factor for developing skin cancer. University students can be considered as a particularly high-risk group for long- and short-term adverse effects of UVR due to intensive solar UVR exposure and high rates of sunburn. While validated questionnaires for assessing solar UVR exposure and sun protection behavior are available in German, a questionnaire for assessing the level of knowledge about this topic is still missing. We conducted a literature search for cross-sectional studies assessing skin cancer and sun protection knowledge among university students in Medline (via PubMed) and analyzed existing questionnaires and topics contained therein. We chose to translate the "Skin Cancer and Sun Knowledge Scale" referring to the TRAPD method into the German language and pilot-tested the translation with an opportunity sample of German students. The literature search revealed 36 eligible studies. Four major topics were identified within the studies: knowledge on skin cancer, risk factors, UVR, and sun protection measures. One hundred and seven German university students (86.0% female) with a mean age of 26.25 years (SD ± 4.58; range: 19-46) participated in our pilot study. The internal reliability of the scale was KR-20 = 0.624. We discovered an improvable level of knowledge in terms of skin cancer among the study population. Statistical analyses revealed no significant associations between the level of knowledge and UVR exposure or tanning behavior, respectively. The skin cancer and sun protection knowledge of German university students should be examined thoroughly. While the psychometric properties of the SCSK require further thorough investigation, first empirical experiences indicate the suitability of the tool to assess the level of knowledge regarding skin cancer and sun protection.

Sun Protective Behaviors and Attitudes of Runners

Sun exposure is a risk factor for skin cancer. Knowledge and behaviors around sun exposure protective measures are poorly described in athletes including runners. Our primary objective was to describe sun exposure behaviors and knowledge in a population of runners. A cross-sectional online survey was administered to 697 runners to measure the frequency of seven sun protective behaviors: sunscreen use on the face or body; wearing a hat, sunglasses, or long sleeves; running in shade; and avoidance of midday running. Between 54% and 84% of runners reported that they engaged in these behaviors at least sometimes, but only 7% to 45% reported frequent use. Of 525 runners who gave a primary reason for not using sunscreen regularly, 49.0% cited forgetfulness; 17.3% cited discomfort; and only a small percentage cited maintaining a tan (6.1%) or optimizing vitamin D (5.1%). Of 689 runners who responded to a question about what factor most influences their overall sun exposure habits, 39.2% cited fear of skin cancer, 28.7% cited comfort level, and 15.8% cited fear of skin aging. In addition to the seven individual behaviors, we also asked runners how frequently they took precautions to protect against the sun overall. We explored associations between participant characteristics and the overall use of sun protection using ordinal logistic regression. Overall, sun protection was used more frequently in runners who were female, older, or had a history of skin cancer. Runners appear to recognize the importance of sun protection and the potential consequences of not using it, but report forgetfulness and discomfort as the biggest barriers to consistent use. Interventions using habit-formation strategies and self-regulation training may prove to be most useful in closing this gap between knowledge and practice.

Sun exposure reduction by melanoma survivors with wearable sensor providing real-time UV exposure and daily text messages with structured goal setting

Despite knowledge of subsequent melanoma risk and the benefit of sun protection in risk reduction, melanoma survivors often do not engage in adequate sun protection and continue to sunburn at rates similar to individuals without a history of skin cancer. This novel intensive intervention provided a wearable UV sensor delivering real-time UV exposure with a smartphone and daily text messages. On days 1-10 (period 1), behavioral facilitation and outcome expectancies messages were provided. On day 10, participants reviewed and reflected on their daily UV exposure on the previous 10 days and set goals for improving sun protection. Then on days 11-21 (period 2) self-efficacy and self-regulation messages were provided. Sixty melanoma survivors were randomized (1:1) to receive structured or unstructured goal setting queries on day 10. Controlling for cloudy/rain conditions with less UV due to weather, there was a time effect with a significant decrease in UV exposure from periods 1-2 [period 1-2, F (59) = 22.60, p < 0.0001]. In this short-term study, melanoma survivors managed their daily UV exposure to stay below their maximum tolerated UV dose. ClinicalTrials.gov Protocol Record NCT0334796, date of registration Nov 15, 2017.

Changing epidemiology and age-specific incidence of cutaneous malignant melanoma in England: An analysis of the national cancer registration data by age, gender and anatomical site, 1981-2018

Background

The incidence of cutaneous malignant melanoma, which is mostly attributable (86%) to UV radiation exposure, has been steadily increasing over the past four decades in predominantly fair-skinned populations. Although public health campaigns are increasing sun-protective behaviour in England, their effect on melanoma incidence is largely unknown. We conducted a retrospective population-based cohort study to examine whether there have been changes in the epidemiology of melanoma in England during the past four decades.

Methods

Individual level data for patients diagnosed with melanoma in England during 1981–2018 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by three age categories (0–34, 35–64, 65+ years), gender and anatomical site during the seven five-year time periods (1981–85 to 2011–15) and the recent three-year period (2016–18). The percentage change in incidence was calculated as change in the average incidence rate from the first (1981–85) to the last time period (2016–18). The Average Annual Percentage Change (AAPC) was estimated using the slope of the linear trend line fitted to the incidence rates by year of diagnosis.

Findings

During the 38-year period (1981–2018), a total of 265,302 cases of melanoma (45.7% males, 54.3% females) were registered in England. The average annual number of cases increased from 837/year in 1981–85 to 6963/year in 2016–18 in males (+732%), and from 1609/year in 1981–85 to 6952/year in 2016–18 in females (+332%). In the young age-group (0–34 years), the average annual incidence rates initially increased from 1981–85 to 2001–05 and then stabilised during the recent period (2006–18). In the middle age group (35–64 years), the rates increased by +332% (AAPC, 10.4%) in males (from 5.6/100,000 in 1981–85 to 24.2/100,000 in 2016–18) and +185% (AAPC, 5.7%) in females (from 10.2/100,000 in 1981–85 to 29.1/100,000 in 2016–18); and in the old age-group (65+ years) the rates increased by +842% (AAPC, 25.7%) in males (from 9.6/100,000 in 1981–85 to 90.4/100,000 in 2016–18) and +381% (AAPC, 11.2%) in females (from 12.5/100,000 in 1981–85 to 60.1/100,000 in 2016–18). The largest increase in incidence in both males and females was observed for melanoma of the trunk (+817%, AAPC, 24.8% in males and +613%, AAPC, 18.3% in females), followed by melanoma of upper limb (+750%, AAPC, 22.9% in males and 518%, AAPC, 15.5% in females).

Interpretation

It appears that the incidence of melanoma among young people in England has stabilised (or levelled off) in recent decades, whereas it continues to increase substantially in older population. These findings suggest that public health campaigns targeted at children/adolescents/parents may be favourably influencing melanoma incidence. The steeper increase in incidence in males is consistent with their relatively greater sun exposure and poor sun-protective behaviour. All the available evidence suggests that the enormous increase in the melanoma of the trunk and upper limb, since the 1980s, is most likely due to increasing trend in intermittent high intensity recreational UV radiation exposure (e.g. sunbathing, holidaying in places with strong sunlight, indoor tanning).

Funding

This work was supported by Brighton and Sussex Medical School (BSMS).

Correlates Between Physical Activity and Sunburn Prevalence Among a Nationally Representative Sample of US High School Students, 2015-2017

BACKGROUND

Physical activity is associated with greater odds of sunburn in adults, increasing harmful sun exposure and skin cancer risk. The authors sought to investigate parallel associations between sunburn and physical activity among US high school students.

METHODS

The authors examined pooled cross-sectional data from the 2015 and 2017 Youth Risk Behavior Survey. A nationally representative sample of 21,894 US high school students who responded to the sunburn question was included.

RESULTS

Prevalence of sunburn was 56.6% between 2015 and 2017. Sunburn prevalence was higher in physically active students (88.3%; 95% confidence interval [CI], 86.7%-90.0%; P < .0001) and student athletes (63.0%; 95% CI, 59.4%-66.7%; P < .0001). Among male students who were vigorously physically active (≥5 d) or on ≥3 teams, the odds of sunburn were 2.33 (95% CI, 1.81-3.00; P < .0001) and 2.52 (95% CI, 1.96-3.23; P < .0001), respectively. Among female students who were vigorously physically active (≥5 d) or on ≥3 teams, the odds of sunburn were 1.65 (95% CI, 1.36-2.02; P < .0001) and 2.92 (95% CI, 2.07-4.13; P < .0001), respectively.

CONCLUSIONS

Many US high school students are affected by sunburn, and the odds of sunburn are elevated during physical activity and team sports participation. Efforts are needed to improve sun safety regulations, education, and resources for youth during school and physical activity.

Sun protection behaviour in organ transplant recipients and non-transplant patients attending a dermatology outpatient clinic in Sweden: A questionnaire survey

BACKGROUND/PURPOSE

Organ transplant recipients (OTRs) are at high risk of developing skin cancer and are therefore advised to protect their skin against ultraviolet radiation from the sun. Specialized OTR clinics with dermatological follow-up may improve sun habits among OTRs. In this study, we compared self-reported sun exposure and sun protection behaviour between OTRs and non-transplant patients (non-TPs) and between OTRs with and without special dermatological follow-up.

METHODS

Patients from Sahlgrenska University Hospital, Gothenburg, Sweden, completed a sun exposure questionnaire. Between 2011 and 2015, 282 OTRs transplanted in the period 1976-2014 and 414 non-TPs were recruited among dermatological outpatients. Participants were stratified into five groups by their status as OTRs or non-TPs and by attendance to dermatological follow-up.

RESULTS

More non-TPs than OTRs reported one or more sunburns in the past year, 46% vs. 20%, P < .0001). More OTRs with than OTRs without dermatological follow-up reported frequent use of sunscreens (63% vs 44%, P = .006). More OTRs with follow-up used one or more sun protection measure such as covering clothes, than other OTRs (54% vs 34%, P = .016).

CONCLUSION

In this study, OTRs reported less sun exposure than non-TPs. Specialized dermatological follow-up seems to improve sun protection behaviour among OTRs. We suggest that specialized OTR clinics should be more broadly implemented.

Photoprotection habits, attitudes and knowledge among school communities in the Costa del sol (Spain)

BACKGROUND

Scholar photoprotection campaigns are among the most effective strategies for preventing skin cancer. Analysis of the target population constitutes a valuable starting point for the implementation of primary prevention strategies. Our aim is to study photoprotection habits, attitudes and knowledge among a Spanish school community.

METHODS

Descriptive cross-sectional study targeting schoolchildren, parents and teachers at 20 schools in the area of the Costa del Sol Health Agency in southern Spain. Two population-specific, validated questionnaires were used: the CHRESI (for children aged 0-10 years) and CHACES Questionnaire(for adults and adolescents aged > 11 years). We collected demographic data, skin colour, skin phototype, sunburn episodes, sun exposure and photoprotection practices, attitudes and knowledge.

RESULTS

1728 questionnaires were analyzed (22% parents, 14.5% teachers, 44.8% adolescents and 18.6% children). The average ages were 8 years (children), 16 years (adolescents), 39 years (teachers) and 42 years (parents). Globally, the predominant features were: male sex (52%), Spanish nationality (92%) and phototypes II-III (61%). Children, followed by adolescents, reported the highest exposure to the sun, both in frequency and in duration. Adolescents had the higher rate of sunburn (75%), followed by parents/teachers (54.1%) and children (44.1%). Children and their parents were the most likely to adopt photoprotection measures, while adolescents presented more risky attitudes. Knowledge regarding photoprotection was acceptable (6.9/10).

CONCLUSIONS

This study highlights the need to improve photoprotection knowledge, habits and attitudes among our target population. Scholars, parents and teachers in our area should be addressed in campaigns to promote healthy sun exposure habits, thus reducing skin cancer-related morbidity and mortality in this region.

The effectiveness of educational programmes in promoting sun protection among children under the age of 18: a systematic review and meta-analysis

Childhood ultraviolet radiation exposure has a strong connection to the development of skin cancer in later life. Therefore, there have been numerous sun protection educational programmes targeted to this age group. However, the association between these have not been well established. This systematic review aims to summarize the evidence on, and assess, the effectiveness of educational programmes in improving sun protection among children under age-18. The protocol was prospectively registered in the PROSPERO database (CRD42020178264). Per PRISMA guidelines, bibliographic databases CENTRAL, OVID (EMBASE, MEDLINE, PsycINFO), LILACS, trial registries, grey literature and other sources were systematically searched for randomized controlled and clinical controlled trials published between database inception to 9 June 2020. Dual independent review of abstracts and full texts was performed. Eligible studies were assessed for methodological quality using the Cochrane risk-of-bias tool. The primary outcome was postintervention scores [standardized mean difference (SMD)] for sun protection (i) knowledge (ii) attitudes and beliefs (iii) behavioural intentions and behaviours. Sidik-Jonkman random effects meta-analysis, sensitivity and subgroup analyses were performed for specific outcomes (sunscreen and sun-safe hat use) which were sufficiently reported. 1350 publications were identified and 24 eligible trials, conducted across 8 different countries, with sufficient aggregate data were included. Small-to-moderate effects of educational programmes were observed across all sun protection outcomes of interest, but negligible effect sizes were demonstrated when specific outcomes were meta-analysed - sunscreen use, SMD 0.18 (95% CI 0.07-0.29; n = 8) and sun-safe hat use, SMD 0.08 (95% CI, 0.00-0.16; n = 6). A promising approach in the future may be to consider targeting children in secondary education with a digitally delivered interactive intervention. Current evidence, however, is insufficient to assess the effects of potential moderators and change in sun protection outcomes is likely not one-size-fits-all. Further research is warranted to direct intervention design and public policy.

The association between citrus consumption and melanoma risk in the UK Biobank

BACKGROUND

Melanoma incidence has been dramatically increasing worldwide. Psoralen, a known photocarcinogen, is naturally abundant in citrus products, leading to the hypothesis that high citrus consumption may increase melanoma risk.

OBJECTIVES

To investigate the association between total citrus consumption and melanoma risk, and the association between individual citrus products and melanoma risk, and to test for interactions between total citrus intake and established melanoma risk factors.

METHODS

Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between citrus consumption and melanoma risk among 1592 cases and 197 372 controls from the UK Biobank cohort. Citrus consumption data were collected via five rounds of 24-h recall questionnaires. International Classification of Diseases codes were used to determine melanoma outcome.

RESULTS

After adjusting for potential confounders, participants in the highest category of total citrus intake (> 2 servings per day) had a significantly increased risk of melanoma (OR 1·63, 95% CI 1·24-2·12) relative to those with no consumption. For individual citrus products, participants with the most orange and orange juice consumption (> 1 serving per day) had a significantly increased melanoma risk relative to those with no consumption (OR 1·79, 95% CI 1·07-2·78 and OR 1·54, 95% CI 1·10-2·10, respectively). Fair- or very fair-skinned participants with high citrus consumption had an even greater melanoma risk (OR 1·75, 95% CI 1·31-2·29).

CONCLUSIONS

High citrus consumption was associated with an increased risk of melanoma in a large, prospective, population-based cohort. Further validation of these findings could lead to improved melanoma prevention strategies.

Age and Cohort Trends of Malignant Melanoma in the United States

Simple Summary

The occurrence of melanoma in the United States is increasing over time. We examined trends in melanoma by birth year and age groups to determine if individuals born more recently experience higher rates of melanoma as they age. We examined these trends separately among men and women and by the location on the body that the melanoma occurred. Melanoma incidence has continued to increase across more recent birth years and varies by body site and sex. Melanoma incidence will likely continue to increase as younger individuals age. While these are mostly thin melanomas, treatment to prevent cancer progression is still costly, both economically and emotionally, for patients.

Abstract

The incidence of malignant melanoma in the United States is increasing, possibly due to changes in ultraviolet radiation (UVR) exposure due to lifestyle or increased awareness and diagnosis of melanoma. To determine if more recent birth cohorts experience higher rates of melanoma as they age, we examined age and birth cohort trends in the United States stratified by anatomic site and cancer type (in situ vs. malignant) of the melanoma diagnosed from 1975–2017. Poisson regression of cutaneous melanoma cases per population for 1975–2017 from the Surveillance, Epidemiology, and End Results (SEER) cancer registries was used to estimate age adjusted incidence for five-year birth cohorts restricted to Whites, ages 15–84. The rate of melanoma incidence across birth cohorts varies by anatomic site and sex. Melanomas at all anatomic sites continue to increase, except for head and neck melanomas in men. Much of the increase in malignant melanoma is driven by cases of thin (<1.5 mm) lesions. While increased skin exams may contribute to the increased incidence of in situ and thin melanoma observed across birth cohorts, the shifts in anatomic site of highest melanoma incidence across birth cohorts suggest changes in UVR exposure may also play a role.

Prevalence and Correlates of Observed Sun Protection Behaviors Across Different Public Outdoor Settings in Melbourne, Australia

Skin cancer prevention efforts in Australia have increasingly incorporated a focus on protection during incidental sun exposure. This complements the long-present messages promoting protection in high-risk settings and avoidance of acute intense bouts of sun exposure. Data from two waves of a cross-sectional direct observational survey was used to assess the prevalence and correlates of N = 12,083 adolescents' and adults' sun protection behavior (arm and leg cover, hat, sunglasses, and shade cover). Individuals were observed in public outdoor settings in Melbourne, Australia during peak ultraviolet (UV) times (11 a.m.-3 p.m.) on summer weekends. Settings included pools and beaches, parks and gardens, and for the first time in 2018, outdoor streets and cafés which may capture more incidental forms of sun exposure and represent another public setting where Australians commonly spend time outdoors. Females and older adults were consistently better protected than males and adolescents. Physical activity was strongly associated with low shade cover across settings. Weather was more strongly associated with sun protection at outdoor streets/cafes and parks/gardens than at pools/beaches but use of observed sun protection (particularly arm cover and covering hat) was low across settings. Continued public education about UV risk and its relation to weather and the seasons is needed to promote the routine use of multiple forms of sun protection during outdoor activities in peak UV times, especially among males and adolescents. Findings also highlight the importance of considering activity demands of public spaces in shade planning to optimize sun protection during outdoor activities in public spaces.

Association of Ultraviolet Radiation Exposure With Dermatomyositis in a National Myositis Patient Registry

OBJECTIVE

Dermatomyositis (DM) has been associated with geospatial differences in ultraviolet (UV) radiation, but the role of individual determinants of UV exposure prior to diagnosis is unknown. The objective was to examine the role of those individual determinants.

METHODS

We analyzed questionnaire data from 1,350 adults in a US national myositis registry (638 with DM, 422 with polymyositis [PM], and 290 with inclusion body myositis [IBM] diagnosed at ages 18-65 years), examining the likelihood of DM compared with PM and IBM diagnosis, in relation to self-reported sunburn history and job- and hobby-related sun exposures in the year prior to diagnosis. We estimated odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression adjusted for age, skin tone, and sex, to determine the association of individual UV exposures with DM diagnosis. We also evaluated the proportion of DM by maximum daily ambient UV exposure, based on UVB erythemal irradiances for participant residence in the year prior to diagnosis.

RESULTS

DM was associated with sunburn in the year before diagnosis (2 or more sunburns OR 1.77 [95% CI 1.28-2.43] versus PM/IBM; 1 sunburn OR 1.44 [95% CI 1.06-1.95]) and with having elevated job- or hobby-related sun exposure (high exposure OR 1.64 [95% CI 1.08-2.49] or moderate exposure OR 1.35 [95% CI 1.02-1.78] versus low or no exposure). Ambient UV intensity was associated with DM in females (β = 3.97, P = 0.046), but not overall.

CONCLUSION

Our findings suggest that high or moderate personal exposure to intense sunlight is associated with developing DM compared with other types of myositis. Prospective research on UV exposure as a modifiable risk factor for DM is warranted.

Does one's geographic location influence their use of sun protection? A survey of 3,185 U.S. Residents

To determine if geographical differences exist in practice of sun protective behaviors across the United States, we performed a retrospective, cross-sectional analysis of data from the Health Information National Trends Survey 4 Cycle 3. Self-reported sun protective behaviors and demographic information were collected for individuals from nine regions across the United States in 2013. Regions followed United States census divisions, including New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain, and Pacific. Study participants included 3,185 people from nine census regions. Sun protection was uncommonly practiced in the United States. The use of sunscreen in the West North Central region was the lowest sun protective practice. Long pants were more commonly worn in the West South Central and the Pacific. Sun protective behavior rates are low for all geographic locations across the United States. Future public health campaigns should place less emphasis on geographical influences of sun protective behaviors and focus more so on comprehensive, nationwide sun prevention campaigns.

Sun Safe Partners Online: Pilot Randomized Controlled Clinical Trial

Background

Harnessing supportive influences in close relationships is an innovative and potentially effective strategy to improve sun protection behaviors.

Objective

This pilot randomized controlled clinical trial evaluates the feasibility and impact of Sun Safe Partners Online, a web-based, couples-focused intervention to improve sun protection behavior.

Methods

A total of 75 couples reporting suboptimal levels of sun protection recruited from Facebook advertisements were randomized to receive a web-based intervention called Sun Safe Partners Online or a Generic Online Sun Safety Information intervention. Sun Safe Partners Online had 4 individual-focused modules and 4 couples-focused modules. Feasibility was assessed by study enrollment, engagement, follow-up survey completion, and intervention evaluation. Participants completed baseline and a 1-month postintervention survey assessing sun protection and exposure, along with individual and relationship attitudes about the importance of sun protection.

Results

Using Facebook as a recruitment strategy resulted in rapid enrollment and higher acceptance than for the prior telephone and print trial. The follow-up survey completion was higher in the Generic Online condition (100%) than in the Sun Safe Partners Online condition (87.2%). Engagement in Sun Safe Partners Online was high, with more than two-thirds of participants completing all modules. Evaluations of Sun Safe Partners Online content and features as well as ease of navigation were excellent. Sun Safe Partners Online showed small effects on sun protection behaviors and sun exposure on weekends compared with the Generic Online intervention and moderate effect size increases in the Sun Safe Partners Online condition.

Conclusions

This study uses a novel approach to facilitate engagement in sun protection by harnessing the influence of relationships among spouses and cohabiting partners. A couples-focused intervention may hold promise as a means to improve sun protection behaviors beyond interventions focused solely on individuals by leveraging the concern, collaboration, and support among intimate partners and addressing relationship-based barriers to sun protection.

Trial Registration

ClinicalTrials.gov NCT04549675; https://clinicaltrials.gov/ct2/show/NCT04549675

Randomized controlled trial evaluating an intervention supporting implementation of sun safety policies in California public elementary schools

Solar ultraviolet radiation (UV) exposure is the primary risk factor for skin cancer and children receive about one-quarter of lifetime UV exposure before age 18. Thus, skin cancer prevention is essential for children. The objective of this study was to test an intervention to facilitate implementation of district sun safety policies. Elementary schools (N = 118) from 40 California public school districts with a school board-approved policy for sun safety were recruited along with one principal and teacher from each school. Elementary schools were randomly assigned to receive the 20-month Sun Safe Schools intervention (N = 58) or to a minimal informational control condition (N = 60). Principals were 47.8 and teachers 44.3 years of age and were predominately female (principals 72.7%; teachers 86.7%) and White (principals 72.0%; teachers 68.2%). The 20-month Sun Safe Schools intervention was delivered to principals and included a coaching session, telephone and email contacts, provision of resources for practice implementation, and a small grant program. The principal (N = 118) and a teacher (N = 113) at each school reported on school sun protection practices 20-months post-baseline. The schools were diverse in student characteristics (M = 64.1% free/reduced price meals; M = 54.5% Hispanic). Intervention principals reported implementing more sun safety practices overall (control M = 2.7, intervention M = 4.2, p < .005) and more practices not present in the district's policy (control M = 0.4, intervention M = 0.9, p = .005). Principals and teachers combined replicated these findings and also reported implementing more practices present in the district policy (control M = 0.9, intervention M = 1.3, p = .005). In sum, the intervention increased sun safety practices in public elementary schools. Trial Registration. This study is registered in ClinicalTrials.gov, www.clinicaltrials.gov, with the identification number of NCT03243929.

Promoting sunscreen use in adolescents playing outdoor sports using UV detection stickers

Sunscreen is a popular form of sun protection and when applied sufficiently (2 mg/cm²) has been shown to block the harmful molecular effects of ultraviolet radiation (UV). This field study tested the effectiveness of UV detection stickers to improve sunscreen use. During a rugby league two-day sporting event (28–29 February 2020) in Queensland, Australia interested players 14–18 years old were provided with access to free sunscreen on DAY-1 and during the subsequent day (DAY-2) were provided with a free UV detection sticker and access to sunscreen. On DAY-2, one UV detection sticker was handed out to 550 attendees. The sunscreen bottles were weighted periodically by research staff throughout both event days. Primary outcomes were sunscreen usage. Overall, 868 g of sunscreen was used across both DAY-1 and DAY-2, with 19% (167 g) of sunscreen used on DAY-1 and 81% (701 g) of sunscreen used on DAY-2. This resulted in a >3-fold improvement in sunscreen use on DAY-2 when the UV detection stickers were provided. We found UV detection stickers may improve use of sunscreen in adolescents during sporting events in high UV environments.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention

OBJECTIVE

Schools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated.

METHODS

Primary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post-test.

RESULTS

More parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun-protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non-implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02).

CONCLUSIONS

A school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public health: Technical assistance for sun safety policies may increase sun protection of children.

Evaluation of Indoor Tanning Facilities in American Fitness Centers

BACKGROUND

Indoor tanning (IT) in fitness facilities encourages a misleading positive relationship between tanning and health. While IT in Canadian fitness facilities has been studied, American literature regarding this topic is lacking.

OBJECTIVES

The objective of this study is to evaluate availability, cost, reported risks, and adherence to legislation of IT in American fitness clubs.

METHODS

This was a cross-sectional study utilizing a telephone questionnaire to survey gyms across all 50 states. The key term "fitness club" was searched in the Yellow Pages and 20 facilities from each state were randomly included into the study. Data were described descriptively and Pearson χ² tests were used to compare IT prevalence and rates of noncompliance between population groups. Regression analysis examined potential relationship between cost and prevalence of IT.

RESULTS

Of the 1000 fitness clubs surveyed, 44.4% (444/1000) offered IT. The overall noncompliance rates for age, rest time, and eye protection were 13.8% (54/390), 26.0% (20/77), and 27.8% (85/225), respectively. The most common risk reported was skin cancer (61.6%), but many facilities were unsure of risks (27.0%) and some described no risk associated with IT (3.2%). The average cost for monthly unlimited tanning was 33 ± 13.96 USD. A state-to-state comparison showed a statistically significant inverse relationship between mean cost and prevalence of IT (P = .013, [r]= -0.35).

CONCLUSION

The prevalence and noncompliance rates of IT in fitness clubs contradict the healthy lifestyles they are working to promote. To limit harms, legislations should be standardized and more strictly enforced. Additionally, public education on IT risks and the use of higher costs may help minimize IT use.

School-Level Factors Associated with Sun Protection Practices in California Elementary Schools

BACKGROUND

This study examined implementation of district sun safety policy in schools and tested correlates of implementation in California public school districts.

METHODS

Principals (N = 118) and teachers (N = 113) in California public elementary schools (N = 118) were recruited and completed a survey on sun protection policies and practices. The sample contained schools whose districts subscribed to the California School Boards Association and adopted Board Policy 5141.7 for sun safety. Principals and teachers reported on implementation of 10 school practices related to BP 5141.7 indicating which practices were implemented in the school.

RESULTS

Years in public education (Exponentiated Score (ES) = 0.51, p < .001), years worked in the current district (ES = 0.49, p < .001), perception that parents should take action to protect children from the sun (ES = 0.43, p < .01), and personal skin phenotype (Low Risk ES = 0.55; High Risk ES = 0.09, p < .05) were associated with number of practices implemented in the school using multiple Poisson regression.

CONCLUSIONS

Policy implementation is more likely among schools with experienced faculty, when parents are seen as important partners in student skin cancer prevention, and when school principals and teachers have a lower personal risk phenotype.

Tanning benefits, seasonal effects, and concerns about sunscreen: Measuring health beliefs about UV among college students

Objective: To develop and validate a scale measuring health beliefs about UV in cloudy climates that may impact UV exposure behaviors. Participants: Students at a large university in Oregon completed pilot (N = 115) and final (N = 335) scales online March-July, 2016. Five participants underwent cognitive interviews. Methods: Expert feedback, cognitive interviews, and pilot data guided item development and refinement. We conducted factor analysis and invariance testing. Results: The final four-factor model fit well (χ² = 37.97, df = 37, RMSEA = 0.000, CFI = 1.000). HBAU subscales are Sunscreen Toxicity, Seasonal Effects, Health Benefits of Tanning, and Tanning Through the Winter. Invariance testing supported strong invariance across sex and tanning status. Conclusion: The HBAU measures beliefs that encourage UV exposure and discourage protection (eg, the belief that sunscreen ingredients are toxic). This scale will enable more comprehensive measurement of cognitive predictors of UV exposure for student health, clinical, and research purposes.

Protection-adjusted UV dose estimated for body areas: Daily self-reported sun protection modification of wearable UV sensor dose

BACKGROUND

During the last 20 years, 50% of adults with sun-sensitive skin have sunburned annually. Reducing the proportion of people who sunburn requires understanding the circumstances and outdoor activities during which at-risk people sunburn.

METHODS

A 7-day observational study of melanoma survivors (n = 20) and young adult first-degree relatives of melanoma survivors (FDRs) (n = 20) captured daily UV exposure, sun protection, and sunburns during spring and summer in the Midwest of the United States (latitude 41.8°N). Participants wore UV and physical activity sensors and completed a daily self-reported survey of sun protection, sunburn, and physical activities. The estimated protection-adjusted UV dose was calculated for each body area by integrating self-reported sun protection with UV sensor dose.

RESULTS

In 254 days, at least one body area in 9 of 20 (45%) melanoma survivors and 11 of 20 (55%) FDRs was sunburned (erythema at 24 hours). Sunburns were associated with spring and walking for transportation or leisure, especially walking the dog. Melanoma survivors used sunscreen daily on the face; however, forearms and lower legs were not protected during walking. Young adults did not use sun protection on the face, forearms or lower legs during walking for transportation and use was ineffective during sports.

CONCLUSION

The sun protection patterns of daily living identified in this study may promote recognition of erythema as sunburn and inform the development of tailored sun protection mobile applications promoting self-monitoring with wearable UV sensors.

The acute effects of ultraviolet radiation exposure on solar dermatitis in Shanghai, China

Ultraviolet radiation (UVR) has long been considered associated with solar dermatitis, but the associations have not been well quantified. To depict the full-range exposure-response association between daily UVR exposures and daily outpatient visits of solar dermatitis. We collected the daily number of outpatient visits of solar dermatitis and monitored hourly ground data of UVR (the sum of A- and B-band) from 1 January 2013 to 31 December 2017 in Shanghai, China. The data were analyzed using the time-series approach, in which overdispersed generalized additive model was used and time trends and weather conditions were controlled for. During the study period, we recorded a total of 15,051 outpatient visits of solar dermatitis. There was a consistently increasing risk of solar dermatitis associated with stronger UVR without a discernible threshold. The effects occurred on the present day, increased to the largest at lag 1 or 2 days, and attenuated to the null at lag 5 days or more. A unit (w/m²) increase in daily maximum-hour UVR was associated with 1.70% (95%CI: 1.19%, 2.20%) increase of outpatient visits of solar dermatitis. Stronger effects occurred among the young people, females, and in the warm season. The risks of solar dermatitis due to UVR exposure would be overestimated if ambient temperature was not adjusted. This study provides quantitative epidemiological estimates for the positive associations between short-term exposure to UVR and increased risks of solar dermatitis. The associations were more prominent among young people, females, and in warm seasons.