Population UV-dose and skin area--do sunbeds rival the sun?

From the perspective of skin cancer risks, sunbed tanning may give the population group of Swedish adolescents a yearly total dose in terms of ultraviolet radiant energy to the skin which is comparable to sunlight. For populations, a dosage scheme is applied, where exposed skin area is estimated to be two to ten times larger in tanning units than in outdoor sunlight. The normal dose fluence rate is multiplied by the exposure time and by the exposed body surface area. A study of sunbed use among adolescents was reinvestigated. Skin dose from artificial tanning in that population group is calculated and compared to sun exposure for erythemally effective radiation and for UVA (315-400 nm). Skin doses from tanning units to the adolescent population agree with estimates based on information concerning sunbed lamp sales/year. For the population, the erythemal skin dose from tanning units exceeds an increase in solar ultraviolet radiation to the skin projected from 10% ozone depletion. The dosage scheme might help to interpret data suggesting an increased melanoma risk among young people using sunbeds > or = 10 times per year. Tanning and sunburns in sunbeds and in sunlight is discussed with regard to skin area.     

Attitudes, subjective norms and perception of behavioural control as predictors of sun-related behaviour in Swedish adults

BACKGROUND: Exposure to ultraviolet (UV) radiation is the major preventable cause of skin cancer. The aim of this study was to investigate the explanatory value of attitudes, subjective norms and perceived behavioural control on behaviours related to UV exposure. METHOD: A random population-based sample (n = 1752, 18-37 years of age) in the Stockholm County, Sweden, answered a questionnaire with items on sun related behaviours and beliefs. The items concerned issues influenced by the Theory of Planned Behaviour, that is, attitudes, subjective norms and perceived behavioural control. Logistic regression analysis was used to examine the associations between behaviours and beliefs. RESULTS: Positive attitudes towards being tanned and being in the sun were both strongly associated with time spent in the sun, intentional tanning, sunbed use, going on vacation to a sunny resort, intention to decrease sunbathing and use of protection against the sun. Perceiving sunbathing as risky was associated with using different ways to protect and intending to reduce sun exposure. Having people around oneself who frequently sunbathe was related to intentional tanning and vacations to sunny resorts. Finally, perceived behavioural control was associated with use of sunscreen and use of other ways to protect from the sun among women. CONCLUSION: The study identified factors on which primary preventive interventions towards decreasing sun exposure should be focused.     

Behavior of sunbed users in Switzerland

OBJECTIVES: A constant rise in the number of skin cancer cases has been observed during the last few years. An important reason for this trend is that exposure of the population to UV radiation is higher. Although natural UV radiation is the major source, exposure due to use of sunbeds must be considered from the point of view of prevention. METHODS: 151 sunbed users in Bern and Basel were questioned on their reasons for visiting a solarium, their behaviour when using a sunbed and their awareness of risks resulting from UV radiation. RESULTS: It was shown that young women are the most frequent sunbed users. Also, sunbeds are often used regularly, not only for cosmetic reasons but also from a desire for relaxing and well-being in the warmth and light. Although most of the persons questioned were aware of certain health risks resulting from UV radiation, this knowledge hardly influenced their behaviour. Thus, more than half the people questioned use sunbeds longer and more often than advised by international recommendations. CONCLUSIONS: In view of a continuing increase in the number of skin cancer cases the improvement of preventive strategies for sunbed users is of major importance. Another urgent requirement is informing the public and increasing the general awareness of possible adverse health effects caused by UV radiation.     

Safety information provided to customers of New York City suntanning salons.

Little is known about the safety information tanning salon operators provide to customers or the extent to which artificial tanning salons adhere to federal regulations designed to protect customers from excessive ultraviolet radiation (UVR) exposure. We surveyed the operators of 20 artificial tanning salons in New York City from 1988 to 1989 concerning salon operating procedures and information provided to potential customers. Results revealed a disparity between known health risks of UVR exposure and safety information provided to tanning salon customers. For example, 75% of salon operators informed potential customers that artificial tanning would not cause a sunburn, and 80% informed potential customers that they would not get skin cancer from artificial tanning. Artificial tanning salons are a rapidly growing industry in the United States, with over two million customers annually. Results from this survey indicate a need for greater regulation of the tanning salon industry and for education of tanning salon operators in the risks associated with the use of artificial tanning devices.     

Multiple skin cancer risk behaviors in the U.S. population

BACKGROUND: The incidence of all types of skin cancer has increased over the past 3 decades in the United States. Increased skin cancer risk is associated with exposure to ultraviolet radiation. This study examined the age-stratified prevalence and correlates of multiple skin cancer risk behaviors (infrequent use of sun-protective clothing, staying in the sun when outside on a sunny day, infrequent use of sunscreen, indoor tanning, and receiving a sunburn) among U.S. adults. METHODS: 28,235 adults participating in the 2005 National Health Interview Survey (NHIS) answered questions regarding sun-protection behaviors, indoor tanning in the past year, and sunburns in the past year. Examined correlates included geographic location, demographics, healthcare access, BMI, physical activity, smoking, alcohol use, melanoma family history, perceived cancer risk, skin sensitivity to the sun, and receipt of a total skin exam. RESULTS: The most commonly reported skin cancer risk behaviors were infrequent use of sun-protective clothing and infrequent use of sunscreen. The majority of individuals reported multiple skin cancer risk behaviors. Although significant correlates varied according to age, individuals reporting more risk behaviors were more likely younger, residing in the Midwest, male, non-Hispanic white, less-educated, smokers, risky drinkers, and had skin that was less sun-sensitive. CONCLUSIONS: The majority of the U.S. population engage in multiple skin cancer risk behaviors. A comprehensive approach to skin cancer prevention requires attention to multiple skin cancer risk behaviors that are common in the U.S. population.     

High-risk sun-tanning behaviour: a quantitative study in Denmark, 2008–2011

Objectives

The incidences of melanoma and non-melanoma skin cancer have increased markedly over the past 30 years. The main risk factor is ultraviolet radiation from the sun and from sunbeds. The Danish Sun Safety campaign was launched in 2007 to curb this development by reducing the exposure of adolescents and young children. In this study, the characteristics of high-risk sun-tanning behaviour were assessed and the effect of the campaign was determined.

Study design

Cross-sectional study.

Methods

Data from annual Internet surveys were compiled in 2008–2011 of 18, 685 15–64-year-old Danes. A tanning index based on sunbed use and intentional tanning in and outside Denmark was the outcome measure in a linear regression model, which included age, gender, skin type, education, income and survey year as exposure variables.

Results

High-risk tanning behaviour was associated with female gender, younger age, shorter education, skin type 3 or 4, higher income, smaller household and living in larger cities. The tanning index, where 100 represent high-risk behaviour, increased by 13.45 points for women as compared with men, dropped by 1.35 points for each 5-year increase in age, rose by 20.72 points for skin type 4 as compared with type 1 and increased by 10.33 points with an income >€105, 409 as compared with <€26, 352. High-risk behaviour decreased during the study period, especially among women and younger people.

Conclusions

High-risk sun-tanning behaviour is linked to certain personal and social characteristics. After initiation of the Danish Sun Safety Campaign in 2007, this high-risk behaviour decreased, especially in the groups initially targeted by the campaign. The campaign may thus reduce the future incidence of melanoma and non-melanoma skin cancer.     

Risk factors for skin cancers: a nested case-control study within the Nurses' Health Study

BACKGROUND: Constitutional factors and sun exposure are associated with skin cancer risk. However, these relations are complex and differ according to skin cancer type. METHODS: We examined the associations of constitutional risk factors and sun exposure with the risks of three types of skin cancer simultaneously and evaluated the interaction between constitutional susceptibility and sun exposure in a nested case-control study within the Nurses' Health Study [200 melanoma, 275 squamous cell carcinoma (SCC), and 283 basal cell carcinoma (BCC) cases, and 804 controls]. Information regarding skin cancer risk factors was obtained from the retrospective supplementary questionnaire. RESULTS: Constitutional susceptibility was an independent risk factor for all three types of skin cancer. Sunlamp usage or tanning salon attendance was a risk factor for melanoma after adjusting for potential confounding variables (OR for ever vs never usage, 2.06, 95% CI 1.30-3.26). Higher sun exposure while wearing a bathing suit was an independent risk factor for all three types of skin cancer. We observed a significant interaction between constitutional susceptibility and sun exposure while wearing a bathing suit on melanoma risk (P, interaction, 0.03); women with the highest susceptibility and highest exposure had an OR of 8.37 (95% CI 3.07-22.84). This interaction was weaker and non-significant for SCC and BCC. CONCLUSIONS: These data largely confirm past studies on risk factors for skin cancer but provide evidence of difference on the strength of these risk factors for melanoma compared with SCC and BCC.     

Sun Safety Among Farmers and Farmworkers: A Review

Farmers and farmworkers face increased risks of skin cancer from exposure to solar ultraviolet radiation (UVR) when working outdoors. The objective of this study was to evaluate the evidence from behavioral and intervention studies from the peer-reviewed studies related to sun safety among farmers and farmworkers and identify any gaps in the literature. A comprehensive review was conducted between 1990 and 2013; 22 studies were identified related to behavior and health interventions of sun safety among these targeted groups. The inconsistency of data collection methods makes it difficult to estimate with accuracy any overall meaningful results of behavior. However, from the studies reviewed, farmers and farmworkers most frequently reported wearing some type of hat (23.6%–100%) as a primary method of protection from the sun when working outdoors. Female farmers were more likely than male farmers to use sunscreen and engage in indoor tanning behavior. All sun safety educational interventions studies reviewed reported positive increases in behavioral change. To a large degree, adequate sun protection is lacking and varies geographically among farmers. Although targeted education is key to making improvements on sun protection behavior, aggressive attempts have to be made. Studies related to farmworkers, sun safety behavior, and skin cancer are scarce and more research is needed in this area.     

Sun Exposure and Protection Index (SEPI) and Self-Estimated Sun Sensitivity

The incidence of skin cancer is increasing worldwide, mostly because of increasing exposure to ultraviolet (UV) radiation from the sun. The Sun Exposure and Protection Index (SEPI) questionnaire, developed in Linköping and validated in Sweden and Australia, is used to map sun habits, sun protection behaviour, and readiness to increase sun protection. We sought to examine differences in sun habits or sun protection behaviour and propensity to increase sun protection, based on SEPI as related to self-estimated skin UV sensitivity according to the Fitzpatrick classification. The study population comprised students at Linköping University, who were asked to complete the SEPI questionnaire. We examined differences in sun habits and sun protection behaviour according to skin type and gender. Individuals with lower UV sensitivity had significantly riskier sun habits and sun protection behaviour and were significantly less likely to increase sun protection. Women spent significantly more time tanning than men, more time in the midday sun, used sunscreen more frequently, and were more likely to seek the shade for sun protection. Individuals with higher UV sensitivity were significantly more likely to increase sun protection; individuals with low UV sensitivity tended to have a riskier attitude to sunbathing. In conclusion, self-estimated skin type and gender are important factors influencing sun exposure habits and sun protection behaviour.     

Concurrent psychosocial predictors of sun safety among middle school youth

Background: Sun‐induced skin damage, which increases skin cancer risk, is initiated in early life and promoted through later sun exposure patterns. If sun safety determinants are well understood and addressed during the school years, skin cancer incidence might be reduced. This study tested psychosocial influences on youth’s sun safety and assessed their strength within and across gender and ethnicity in a sample of 1782 middle school students. Methods: Predictors included sunburn and skin cancer knowledge, tanning attitudes, peer norms, and barriers regarding sun exposure and were assessed with a self‐administered, validated questionnaire. The hypothesized relationships were tested with structural equation models and confirmed with multilevel regression. Results: Across gender and ethnicity, knowledge emerged as an important sun safety predictor with both direct and indirect effects mediated through tanning attitudes. The relationship with barriers did not reach statistical significance within any of the subgroups, possibly due to measurement limitations. An indirect effect of peer norms on sun safety, mediated through tanning attitudes, was confirmed only among girls. Also, an indication that peer norms operate differently within the ethnic groups was found, since this predictor had a statistically significantly stronger relationship with sun safety among non‐Hispanics. Conclusions: Youth’s sun safety is a multifactorial practice, partially determined by ethnicity‐ and gender‐based standards. In order to ensure health‐promoting school environments, needed are multicomponent programs where peer norms and knowledge are salient and where sun safety is addressed individually and together with other health risk behaviors.     

Occupational exposure to ultraviolet radiation: a health risk assessment

This review applies health risk assessment methodology to the subject of occupational exposure to ultraviolet radiation (UVR). Ultraviolet radiation is produced by many sources, and for most people the sun is their main source of exposure. In the occupational environment, there are also many artificial sources, of which welding arcs are the predominant and most intense. Adverse health effects include photokeratitis, erythema, pterygium, some types of cataract, non-melanocytic skin cancer, and malignant melanoma. Outdoor workers and workers who are exposed to certain artificial sources (particularly welding arcs), frequently are exposed to UVR levels that are above the current exposure limits. Such workers may also be at an additional risk of developing nonmelanocytic skin cancer along with other chronic conditions, including malignant melanoma. A range of control measures is available but nevertheless, many workers (particularly those exposed to solar UVR) do not make full use of these measures. Therefore, the implementation of health education campaigns and other initiatives that encourage use are needed. Overall, although exposure to UVR presents a substantial risk for certain occupations, the current exposure standards and currently available control measures (if used) are considered to provide adequate protection for most workers.     

Test-retest of self-reported exposure to artificial tanning devices, self-tanning creams, and sun sensitivity showed consistency

OBJECTIVE: Exposure to ultraviolet radiation has consistently been linked to an increased risk of melanoma. Epidemiologic studies are susceptible to measurement error, which can distort the magnitude of observed effects. Although the reliability of self-report of many sun exposure factors has been previously described in several studies, self-report of use of artificial tanning devices and self-tanning creams has been less well characterized. STUDY DESIGN AND METHODS: A mailed survey was re-administered 2-4 weeks after completion of the initial survey to 76 randomly selected participants in a case-control study of melanoma. Cases and controls were individuals diagnosed in 1999 and 2000 who were ascertained from the Iowa Cancer Registry in 2002. We assessed the consistency of self-reported use of sunlamps and self-tanning creams, sun sensitivity, and history of sunburns. RESULTS: There was substantial reliability in reporting the use of sunlamps or self-tanning creams (cases: Kappa (kappa)=1.0 for both exposures; controls: kappa=0.71 and 0.87, respectively). kappa estimates of 0.62-0.78 were found for overall reliability of several sun sensitivity factors. CONCLUSION: Overall, the survey instrument demonstrated substantial reproducibility for factors related to the use of sunlamps or tanning beds, self-tanning creams, and sun sensitivity factors.     

Elektrosmog, Handys, Solarien usw.—Gesundheitsrisiken durch Strahlung?

This review supplies a survey of the three physical influences, i. e. UV radiation, high-frequency electromagnetic fields of radio telephone systems and other wireless radio applications as well as low-frequency fields of electric power supply. The exposure to UV radiation must be considered to be by far the highest health risk. The annual rate of about 2000 deaths from skin cancer in Germany, mainly caused by extensive exposure to solar UV radiation, demands protective measures. Teaching reasonable behaviour is the supreme issue. Recommended protective measures in the order of their effectiveness are protection by adaptation of behaviour, by clothes, sun hats and sunglasses as well as by sun creams. Children are the most important target group. With regard to UV tanning appliances it is recommended not to use artificial UV radiation for cosmetic purposes because of the related health risks. For the assessment of health impairments caused by exposure to electromagnetic fields, direct field reactions due to induced electric body currents, reactions on the surface of the body or heating effects should be separated from indirect field reactions (e. g. electric shocks and burns) due to contact currents or interference with electronic body aids and implants. Risk assessment has led to recommendations of threshold values which-in agreement with international research results-exclude all impairments of health caused by direct field reactions scientifically proven to date. Contrary to public concerns, which are mostly related to base transmitters of radio telephone systems, exposure due to handheld radio telephones (cellular phones) should rather be considered from the viewpoint of precautionary health protection, since it is more likely that their use can lead to high exposure of the user. Due to the protective measures provided so far and observance of the threshold values based on scientific results, exposures do not lead to health impairments-not even in children. Because of the introduction of new technologies more portable devices are to be expected that may be operated near the body. This will further increase the exposure of people to high-frequency electromagnetic fields.     

Cohort profile: The QSkin Sun and Health Study

The QSkin Sun and Health Study comprises a cohort of 43 794 men and women aged 40-69 years randomly sampled from the population of Queensland, Australia in 2011. The cohort was established to study the development of skin cancer and melanoma in the population with the highest reported incidence of these diseases in the world. At baseline, besides demographic items and general medical history, information about standard pigmentary characteristics (including hair and eye colour, freckling tendency, tanning ability and propensity to sunburn), past and recent history of sun exposure and sunburns, sun protection behaviours, use of tanning beds and history of skin cancer was collected by self-completed questionnaire. Participants have given their consent for data linkage to the universal national health insurance scheme and for linkage to cancer registries and pathology databases, thus ensuring complete ascertainment of all future skin cancer and melanoma occurrences and medical treatments and other cancer events. Linkage to these registers will occur at predetermined intervals. Approval to access QSkin data can be obtained on application to the study investigators and submission of a formal research plan that has previous approval from the human research ethics committee of the applicant's institution.     

The impact of an appearance-based educational intervention on adolescent intention to use sunscreen

During adolescence, there is a steady decline in the use of sun protection and increased use of indoor tanning lights. Previous health education efforts have changed knowledge but not these behaviors. Middle school students (n=113) received a single educational class that included personal viewing of skin changes visible under ultraviolet (UV) filtered light. Pre-/post-surveys assessed past, current and future intent to use sunscreen, as well as sun benefit and sun risk attitudes. Prior to the session, 42% were sunscreen non-users and 21% were consistent users. At post-test, one-third of students who had not previously intended to use sunscreen in the next month now intended to use it. Among students who had seen skin damage, 59% reported intention to use sunscreen in the next month versus 35% who did not see skin changes (P = 0.04). Viewing sun damage was an independent predictor of intent to use sunscreen in the next month (OR 2.9, P = 0.04), as was older age (OR 2.6, P = 0.04) and previous consistent sunscreen use (OR 6.1, P = 0.004). A brief educational intervention that emphasizes risk-to-appearance and personalizes the risks of UV exposure has the potential to influence early adolescent sun protection. Long-term studies of this approach are needed.     

Risk perception, optimistic bias, and readiness to change sun related behaviour

BACKGROUND: The incidence of skin cancer has had a rapid increase in Sweden during the last 20 years. Sun exposure is an important preventable risk factor for skin cancer. It is essential to develop interventions to change people's exposure to the sun. The perception of own susceptibility to harm is essential in theories about self-protective behaviour. The aim of the present paper was to examine the associations between different risk perceptions, sun-related behaviour, readiness to change, and optimism bias. METHOD: A total of 722 visitors of a mobile skin cancer screening unit answered a questionnaire in the summer of 2001. The campaign was conducted at five different locations in Sweden. RESULTS: The participants in this study seemed to have realistic believes about the contribution of solar radiation to the risk of developing skin cancer, however, they seriously underestimated skin cancer incidence in the population and the impact of skin cancer on general health. CONCLUSION: People concerned about skin cancer seem to be aware of the fact that sun exposure is an important risk factor for skin cancer, but they fail to use this information in a consistent way to formulate a judgment of their own vulnerability to harm. People need to be informed about the high incidence of skin cancer, the personal risk factors of skin cancer, and the fact that unintentional as well as intentional sun exposure increases the risk of developing skin cancer.     

Suntanning and risk of cutaneous melanoma: a literature review

Epidemiological studies suggest a relationship between suntanning habits and high risk of melanoma. A literature review was carried out for the period between 1977 and 1998 using Medline and Embase (Excerpta Medica) databases. The analysis showed that intentional sun exposure is highly prevalent among youths, despite their awareness of the risks involved in excessive exposure to ultraviolet radiation and their knowledge on skin protection measures. Intentional exposure is a habit fostered by certain beliefs and attitudes towards suntanning and stimulated by peer pressure and aesthetic referents. The most common tanning practices involve a high risk of developing melanoma. It was concluded that the most effective means to prevent melanoma is mass media dissemination of the concept that having a tanned skin is not healthy -- since it implies the skin being damaged by solar ultraviolet radiation -- and education campaigns for effectively changing people's behaviors and their motivations.     

Cancer-preventive effects of sunscreens are uncertain

Provocative findings have been published suggesting that the use of sunscreens may promote skin cancer. A recent meeting of international experts on the use of sunscreens and skin cancer was held at the International Agency for Research on Cancer in Lyon. The workshop concluded that the topical use of sunscreens reduces the risk of sunburn and that sunscreens probably prevent squamous-cell carcinoma of the skin when used mainly during unintentional sun exposure. No conclusion could be drawn about the cancer-preventive activity of topical sunscreens against basal-cell carcinoma and cutaneous melanoma. The use of sunscreens can extend the duration of intentional sun exposure, such as sunbathing. Such an extension may increase the risk for cutaneous melanoma. The workshop warned against relying solely on sunscreens for protection from ultraviolet radiation.     

Is the current public health message on UV exposure correct?

Current sun safety messages stress the importance of sun protection in avoiding the consequences of excessive exposure to ultraviolet radiation (UVR), such as skin cancers, cataracts and other eye diseases, and viral infections caused by UV-induced immunosuppression. However, adequate exposure to UVR has an important role in human health, primarily through UV-induced production of vitamin D, a hormone essential to bone health. Vitamin D insufficiency may be associated with increased risks of some cancers, autoimmune diseases and mental health disorders such as schizophrenia. Here, we review the evolution of current sun exposure practices and sun-safe messages and consider not only the benefits, but also the detrimental effects that such messages may have. UVR-induced vitamin D production can be inhibited by factors such as deep skin pigmentation, indoor lifestyles, older age, sun avoidance behaviours and clothing habits that limit skin exposure, with deleterious consequences for health. There is some early evidence that sun-safe messages are beginning to cause a decrease in skin cancer rates in young people. After the widespread promotion of sun safety, it may now be appropriate to refine public health messages to take better account of variations between groups and their susceptibility to the dangers and benefits of sun exposure.