Skin cancer prevention

Evidence statement ER3.2

Three studies (two [‑] and one [+]) report low perceptions of susceptibility to skin cancer among children and older adults.

Evidence statement ER3.5

According to four studies (two [+] and two [‑]), perceived severity of sun exposure was low in children, young adults, older adults and sunbed users. Children were more aware of the short‑term discomfort of sun exposure than long‑term risks (one study [+]). Studies in adults (two [+] and two [‑]) found skin cancer was thought to be easily cured, a possible future concern, something people preferred not to think about or outweighed by the perceived short‑term benefits of a tan.

Evidence statement ER3.6

Four studies (three [+] and one [‑]) suggest that photo‑ageing was taken seriously by participants, especially women, in one case suggesting that this was perceived as a more serious and real concern than skin cancer.

Evidence statement ER3.9

One study (+) suggests that knowledge of the benefits of sun protection may not be translated into safe sun practices, as a tan is seen as socially beneficial.

Evidence statement ER3.10

One study (‑) found older adults may have misinformation about the causes of skin cancer, limiting their perceptions of the benefits of sun protection. In addition, four studies (two [+], one [++] and one [‑]) revealed erroneous beliefs that getting a tan was protective of skin damage and in two studies (both [+]), participants believed that getting burnt was the prelude to a deep tan, and that high protection sunscreen might prevent deep tanning.

Evidence statement ER3.12

Seven studies (two [‑], four [+] and one [++]) showed that tanned people are seen as healthy by children, adolescents and adults. One study (+) reported that the sun was positively regarded as a source of vitamin D.

Evidence statement ER3.13

Three studies (from Scotland, Australia and Canada) (two [+] and one [++]) describe negative associations with white, untanned skin, which was described as unhealthy and indicative of being unfit.

Evidence statement ER3.14

Seven studies among children, adolescents and adults (two [‑], four [+] and one [++]), describe tanned skin as being physically attractive. Two studies (both [+]) thought that bad skin and acne were cleared up by UV exposure.

Evidence statement ER3.15

Peers are reported as an important influence on UV exposure in three studies among adolescents and sunbed users (two [+] and one [++]) as they may react positively to tans.

Evidence statement ER3.16

Two UK studies (one [‑] and one [+]) show that a tan signifies a good holiday, especially a holiday abroad, and could be seen as a necessary 'symbolic souvenir'.

Evidence statement ER3.17

Sun protection through use of sunscreen, wearing hats and covering up with long sleeves all had limitations. Sunscreen use is seen as a hassle in six study reports of qualitative research (three [+] and three [‑]) due to its expense, mess, time to apply and potential to cause irritation or allergies.

Evidence statement ER3.18

In three studies (two [‑] and one [+]), parents say that children were uncooperative when it came to applying sunscreen.

Evidence statement ER3.19

Four studies (two [‑] and two [+]) highlight impracticalities of hat‑wearing which limits children's activities, and may be rejected as unfashionable.

Evidence statement ER3.20

In three studies (one [‑] and two [+]), covering up through wearing long‑sleeved tops was seen as uncomfortable in the heat. Rash vests and wetsuits may be better for young children on the beach, as t‑shirts may be repeatedly removed (two [‑] studies).

Evidence statement ER3.21

Three studies (two [‑] and one [+]) discuss structural or policy limitations to skin cancer prevention in schools, such as limited ability to change scheduling around lunchtime to avoid the hottest part of the day.

Evidence statement ER3.22

Provision of shade outside is seen as a possible strategy, but costly and not always easy to use by playing children (two [‑] and one [+]).

Evidence statement ER3.23

Eight studies of qualitative research (four [+], three [‑] and one [++]) discuss the limitations of parental responsibility for protecting children from sun exposure.

Evidence statement ER3.24

Four studies (one [‑] and three [+]) discuss the responsibility of parents for their children's safe‑sun behaviour. This responsibility may be limited by parents' failure to demonstrate sun‑safe habits themselves due to ambivalence about their own desire for tanned skin (one [‑] and one [+]). In addition, parents are not always with their children to ensure safe‑sun behaviour (one [+] study).

Evidence statement ER3.25

Five studies (one [‑], three [+] and one [++]) note that the transition from child to adolescent is marked by increasing independence, or rebellion, and that this may have negative effects on safe‑sun behaviour.

Evidence statement ER3.27

'Incidental tanning', obtained by simply being outdoors, was seen positively in seven studies of qualitative research, for both children and adults (three [+], three [‑] and one [++]).

Evidence statement ER3.28

Such attitudes to this incidental sun exposure, makes sunscreen use less likely on overcast days (one [+]), in the winter (one [+] and one [‑]), and for children when going out to play somewhere other than the beach (one [+]) or for a shorter time than the whole day (one [‑]). People in the UK may be more likely to use sunscreen on holiday abroad than when at home (one [‑]).

Evidence statement ER3.29

Eleven studies qualitative research (five [+] and six [‑]) discuss people's cues to protective action against UV exposure. These include the positive influence of parents and other adults for younger children (one [+] and one [‑]) and peers for older children (one [‑]), knowing someone who has had skin cancer (two [+] and two [‑]), and media campaigns (six [‑] and three [+]).

Evidence statement ER3.31

Media campaigns need to engage younger children (two [‑] and one [+]) while not alienating older children (one [+] and one [‑]), it is also suggested that they need to change regularly to maintain their impact (one [+]) and that shock images may appeal to older boys (one [‑]).

Evidence statement ER3.32

Two studies of UK‑based qualitative research address self‑efficacy in skin cancer prevention with participants reporting examining themselves for signs of skin cancer (one [+] and one [‑]). Skin cancer is understood as largely preventable and identifiable early, by those taking personal responsibility for their skin through self‑surveillance and personal responsibility (one [+]).

Evidence statement ER3.33

One qualitative study (++) uses the analytic constructs of framing and narrative to understand the differences in the construction of skin cancer public health policy in Australia, Canada and England. While skin cancer is conceived as a growing public health issue in England, public health messages focus on expectations of reasonable protective factors and moderate UV exposure. This is because the population is not considered sensitised to skin cancer and does not want to hear messages that promote avoiding the sun.

Evidence statement ER3.34

One qualitative study (+) uses cognitive interviewing to refine the way questions were asked for a survey tool. The capacity for misunderstanding that it demonstrates underlines the importance of piloting any information material aimed at primary prevention of skin cancer with target groups.

Evidence statement ER4.1

There is a limited body of evidence on the effect of change to the natural or built environment in the prevention of skin cancer in educational settings and no evidence from other settings. No studies were identified that focused solely on the impact of changing the timing of outdoor activities.

Evidence statement ER4.2

There was evidence from a single good quality (++) randomised controlled trial (RCT) undertaken in Australia that adolescents in years 7 to 12 used rather than avoided newly provided sail shade areas at secondary schools, during lunch time periods. An extra 2.7 students were observed to have used the shaded sites (95% confidence interval [CI]: 0.7 to 4.7) during Spring/Summer term compared to unshaded sites in the control schools (p=0.011).

Evidence statement ER4.5

Three studies focused on implementation, one (++) study reported that, on average, only six students used the shaded areas at any one time, despite the relatively large size of the sails. The authors suggest that optimal use of shade sails may be limited by friendship groups avoiding encroaching on other student's space. One (‑) study did not contain evidence pertinent to the secondary review questions. Another (‑) study reported that all subgroups had lower UVR exposure at the shaded site compared to the unshaded site except for boys aged 1 to 4 years who were exposed to 23.1% compared to 16.7% of available UVR at the shaded and unshaded sites respectively. In this later (‑) study gender and environment (high and low quality) were statistically significant predictors of step count a linear mixed model.

Evidence statement ER5.1

Two studies (both [++]) report that the experience of melanoma or pre‑cancerous moles by participants or people they know, or a family history of malignant melanoma, increase perceived risk.

Evidence statement ER5.2

Five studies (three [‑] and two [++]) report that the risk of skin cancer is not appreciated or is seen as not of immediate concern. This perception is particularly stated by children (aged 6 to 8 years) and young people (aged 12 to 25 years approximately), who view the risk as too distant to be a serious concern.

Evidence statement ER5.4

Three studies of adults (one [++], one [‑] and one [+]) report that people are aware of the risks of skin cancer, but avoid thinking about them, or adopt an optimistic framing that minimises their own perceived susceptibility, such as assuming that others' exposure to risk factors must be higher than their own.

Evidence statement ER5.5

One US study (++) discusses the communication of risks within families where a member has had an experience of skin cancer. It found that people diagnosed with cancer usually discussed risk with their families, and that women took a leading role in communication.

Evidence statement ER5.6

Five studies of young people and adults (two [++], two [+] and one [‑]) report the belief that sun exposure provides 'resistance' to skin damage, burning or cancer in the future. In particular, outdoor workers reported such beliefs in two studies (one [‑] and one [+]), and parents in one (++).

Evidence statement ER5.8

Perceived severity of skin cancer was low in seven studies across a wide range of age groups (aged 6 years to over 60 years) (four [++], two [+] and one [‑]). In three studies participants thought that skin cancer was easy to treat (all [++]). In one study (++) with participants aged 6 to 8 years, there was a lack of understanding about what skin cancer was or the risks of skin cancer. A study of farmers in the USA (+) finds that they did not see skin cancer affecting their day‑to‑day work.

Evidence statement ER5.9

Seven studies (three [++], three [+] and one [‑]) report that skin ageing was seen as a serious consequence of sun exposure. Two studies (one [++] and one [+]) find that skin ageing is perceived as a more serious consequence of sun exposure than is skin cancer. Four studies (two [++] and two [+]) report that skin ageing is seen as a more serious consequence by women than it is by men.

Evidence statement ER5.10

Participants in most studies (two [++] and two [+]) used sun protection, principally sunscreen, in order to offset the perceived risks of sun exposure including skin cancer and skin ageing (two [+] and one [++]). Avoiding sunburn and the sun's heat and glare were mentioned as a benefit of sun protection in three studies (one [+], one [‑] and one [++]).

Evidence statement ER5.11

Participants in two studies (one [+] and one [++]) said that using sun protection enabled them to stay in the sun for longer when playing sports.

Evidence statement ER5.12

Two studies (one [‑] and one [++]) of parents and school staff stated the benefits of promoting sun protection to young people to help them acquire positive long‑term habits.

Evidence statement ER5.13

Twelve studies (six [++], three [+] and three [‑]) report positive perceptions of a tanned appearance, that is, that a tanned appearance is perceived as attractive. Two studies (one [++] and one [+]) report that a tanned appearance increases confidence and self‑esteem.

Evidence statement ER5.14

Three studies (two [++] and one [+]) report that the degree of tan colour was important in shaping perceptions of tanned appearance, with a deep tan not necessarily seen as desirable.

Evidence statement ER5.15

Nine studies (five [++], two [+] and two [‑]) found that a tanned appearance is seen as healthy. Of these, three studies (all [++]) note that a tanned appearance indicates an active, outdoors lifestyle.

Evidence statement ER5.16

Three studies (one [++] and two [+]) report the belief that ultraviolet exposure is beneficial because it provides vitamin D.

Evidence statement ER5.17

Two studies (one [++] and one [+]) report that sun exposure is believed to protect against future skin damage or cancer by increasing 'resistance'.

Evidence statement ER5.18

Three studies discuss the perception that outdoor activities which involve sun exposure are healthier than indoor activities, both among adults (two [++]) and children (one [‑]). One study (‑) finds this perception to be linked to the freedom to play actively for children.

Evidence statement ER5.19

Participants in three studies (all [++]) distinguished deliberate from incidental tanning, and expressed the belief that incidental tanning was less dangerous or less likely to require protection.

Evidence statement ER5.20

One study (++) finds that participants preferred to see themselves as tanning incidentally, rather than deliberately. This may be because deliberate tanning has 'unhealthy' connotations but incidental tanning from outdoor activities does not.

Evidence statement ER5.21

Three studies (two [+] and one [++]) compared sunbed use to sun exposure. Most of the participants in these studies believed that sunbeds were more dangerous than sun exposure.

Evidence statement ER5.22

Six studies (five [++] and one [‑]) identify the unfashionable or unattractive appearance of protective clothing as a barrier to their use among children and young people (aged 6 to 20). Two studies (one [‑] and one [++]) find that protective clothing, such as hats, would be more acceptable if they were fashionable and attractive.

Evidence statement ER5.23

Three studies (one [++] and two [+]) find that young adult and adult participants see sun protection behaviour as not strongly supported by social norms within their communities.

Evidence statement ER5.24

Five studies (one [++], two [+] and two [‑]) describe a strong association between sunscreen use and particular contexts, such as the beach and being on holiday.

Evidence statement ER5.25

One study (++) finds that young people (ages 12 to 17 years) see media messages and parental behaviours regarding sun protection as focused on young children and not relevant to themselves.

Evidence statement ER5.26

One study (+) finds that men see sunscreen use as unmasculine.

Evidence statement ER5.27

Ten studies (four [++], three [+] and three [‑]) described the inconvenience of sun protection resources as barriers to their use. The particular issues which contribute to the perception of inconvenience are: the need to carry and remember sun protection resources (one [+], one [‑] and one [++]); the 'messiness' of sunscreen (three [+], two [‑] and one [++]); the awkwardness of hats and sunglasses which may fall off or interfere with activities (two [++] and one [+]); and the inconvenience of making use of shade structures by children and young people (one [‑]).

Evidence statement ER5.28

Four studies (two [++], one [+] and one [‑]) describe physical discomfort as a barrier to the use of protective clothing.

Evidence statement ER5.29

One study (++) finds that school staff see a number of practical barriers to encouraging children to use sunscreen before outdoor activities, including monitoring application, touching children to help with application, students sharing sunscreen, and parental permission.

Evidence statement ER5.30

Six studies (three [++], two [+] and one [‑]) said that the cost of sun protection resources was a barrier to their use. This primarily concerned sunscreen purchased by individuals, with one study (‑) mentioning the cost of hats as a barrier to implementing compulsory hat policies in low socioeconomic status (SES) schools, and one (++) the cost of installing shade structures in schools. However, one study (+) that focused on farmers in the USA said that cost was not a barrier.

Evidence statement ER5.31

Other practical barriers to sun protection are: children being uncooperative with the application of sunscreen (one [++] and one [+]); the perceived ineffectiveness of sunscreen in stopping burning (one [+]); and the perception of adverse health consequences of sunscreen use such as acne (one [+] and one [++]), allergic reactions (one [++]), and potential long‑term toxicity (one [++] and one [+]).

Evidence statement ER5.32

One study (++) reports potential institutional barriers to sun protection in schools, including: the cost of implementing new policies for schools; time constraints on school staff; the difficulty of changing outdoor structures to provide shade; concerns about liability; and the need for staff training.

Evidence statement ER5.33

Two studies (one [++] and one [‑]) found that some school staff felt that sun protection was not a high‑priority issue, because of the limited time children spent outdoors. Participants in one study (‑) felt that sun protection detracted from teaching and in one other study (++), school staff said they felt overwhelmed with policies and initiatives on a wide range of issues.

Evidence statement ER5.34

Effective communication with parents was identified as a potential barrier in one study (++). The cost to parents was also mentioned as a concern relating to compulsory hat regulations in one study (‑).

Evidence statement ER5.35

Six studies, most in school settings, found that children aged 6 to 8 years (one [++]), young people aged 12 to 17 years (three [++] and one [‑]), and young adults aged 18 to 25 years (one [+]) identified parents, especially mothers, as important sources of positive encouragement and practical support for adopting sun protective behaviours. One further study (+) of older women aged 75 to 90 years found that as children, they had also been positively influenced by parents. Other adults, such as teachers and lifeguards, were identified as sources of positive encouragement for children aged 6 to 8 years (one [++]) and young people aged 8 to 17 years (one [‑] and one [++]) to adopt sun protective behaviours.

Evidence statement ER5.36

Seven studies found differences between children (approximately 8 to 13 years) and older young people (approximately 14 to 17 years) in sources of positive encouragement to use various forms of sun protection. One study (++) found that parents or carers apply sunscreen more often to younger children, while older children are more likely to apply it themselves. Five studies (three [++] and two [‑]) found that younger children are more likely to listen to parents (or other adults such as teachers) advice to use sun protection such as sunscreen or clothing, because of their role as authority figures. Older young people are more likely to be influenced by their peers. Young people in these studies described the shift towards peer influence as part of a process of asserting their independence from authority. However, the remaining study (++) found that older young people (aged 16 to 17 years) felt themselves to be more receptive to health messages than younger children.

Evidence statement ER5.38

Adults and young people in five studies (four [++] and one [‑]) stated that knowing someone with skin cancer may act as a cue to adopt sun protection behaviours in general.

Evidence statement ER5.39

Two studies from New Zealand and the US (one [‑] and one [++]) found that primary school staff were willing to implement school‑wide sun protection policies such as: physical shade structures or trees; 'no hat, no play' or 'no hat, play in the shade' rules; provision of free sunscreen; or rescheduling outdoor activities. Obtaining funding for such policies, especially environmental change, was a barrier in some cases. One further Australian study (++) notes that policies such as 'no hat, no play' are common in Australian primary schools, but are rare in secondary schools.

Evidence statement ER5.41

One study (++), a process evaluation of a sun protection intervention ('Pool Cool') at outdoor pools, finds that signs, sunscreen pumps and shade structures were viewed positively and frequently used by pool‑goers.

Evidence statement ER5.42

In one study (++), recreation staff indicated that few sun protection policies had been implemented, and were conscious that staff often did not model good sun practice, but were generally willing to implement sun protection policies.

Evidence statement ER5.44

Three studies (one [++], one [+] and one [‑]) of young adults (18 to 25 years) and adults discuss the influence of the media on individuals' behaviour. All of these studies show the belief that representations in the media may have an adverse effect on sun protection behaviours.

Evidence statement ER5.45

Three studies from the USA and Australia (two [++] and one [‑]), show people of all age ranges to be more likely to use sun protection in general in summer and in sunny weather.

Evidence statement ER5.47

Two studies (one [++] and one [‑]) describe adults (aged 16 to 54 years) putting on a T‑shirt or applying sunscreen only after beginning to burn.

Evidence statement ER5.48

Five studies identify factors which could be addressed by resource provision interventions such as making available sunscreen or protective clothing. These factors include the cost of sunscreen (two [++] and two [+]), and the inconvenience of remembering to carry sunscreen (one [+] and one [‑]) or protective clothing (one [++]). These barriers appear to be particularly relevant for children and young people (aged 8 to 25 years).

Evidence statement ER5.50

Two studies (both [++]) investigate service providers' views towards potential resource provision interventions, finding that school staff and leisure staff are positive about the potential to implement sun protection interventions. However, they have concerns relating to practical requirements such as time and funding, and are not always confident that their own roles and responsibilities will be clearly defined.

Evidence statement ER5.51

A wide range of other barriers are identified in the studies. These include physical discomfort (two [++]; one [+] and one [‑]), inconvenience of use (four [++], three [+] and three [‑]) and social barriers including appearance and prevailing norms (five [++], two [+] and one [‑]). Not all resources are acceptable to all targeted populations.

Evidence statement ER5.53

One study (‑) found that using environmental shade may reduce the spontaneity of outdoor activities, especially for younger children. One study (++) found that school authorities see the cost of providing environmental shade as a barrier.

Evidence statement ER5.57

Five studies (three [‑] and two [++]) found that people do not think skin cancer is a serious risk. Twelve studies (six [++], three [+] and three [‑]) found that a tanned appearance is considered attractive.

Evidence statement ER5.58

Three studies (all [++]) found that incidental tanning is perceived as less risky than deliberate tanning. The use of protection is associated with deliberate tanning, such as at the beach, in three further studies (two [+] and one [++]). This suggests that sun protection is seen as less salient where sun exposure is incidental and not deliberate. Two studies (one [++] and one [+]) indicate that this may be particularly true for men.

Evidence statement ER5.59

Three studies found that service providers, including school staff (one [‑] and one [++]) and leisure staff (one [++]), have positive attitudes towards resource provision and environmental change interventions. However, two studies (both [++]) report concerns about the potential extension to their responsibilities, and one study (++) raises the prospect of an overload of policies and recommendations.

Evidence statement ER5.60

Two studies (one [+] and one [‑]) found that men were less likely than women to deliberately sunbathe, but also less likely to use sun protection. Three studies report the perception that sunbathing (one [++]) or sunbed use (one [++] and one [‑]) are unmasculine.

Evidence statement ER5.61

Three studies (two [++] and one [+]) found that women, especially mothers, tend to take the lead role in promoting sun protection behaviours within the family.

Evidence statement ER5.62

Four studies (two [++] and two [+]) found that women were more concerned than men about how the sun affects their appearance, both negatively (skin ageing and wrinkles) and positively (tanned appearance).

Evidence statement ER5.63

Seven studies (four [++], two [+] and one [‑]) found that young children are more likely to be influenced by parents, particularly mothers, and school staff.

Evidence statement ER5.64

Four studies (three [++] and one [‑]) found that adolescents are less likely to be influenced by authority figures and adults and may assert their independence by not following sun protection messages. One study (++) found that adolescents see sun protection as primarily concerning younger children.

Evidence statement ER5.65

Four studies (two [‑], one [++] and one [+]) found that parents of young children are more receptive than the general population to sun protection messages. However, three studies (two [‑] and one [++]) found that parental concern relating to young children's sun exposure does not necessarily translate into concern about their own sun exposure, or to that of older children.

Evidence statement ER5.67

Two studies (one [‑] and one [+]) focus on the views of outdoor workers. Both these studies found that outdoor workers do not feel that sun protection is a priority, and that they have little awareness of the risks of sun exposure.

Expert papers

The seven expert papers with explicit links to the recommendations were:

Economic analysis reports

Review 1

The review of studies on providing information to prevent skin cancer failed to identify any existing UK‑based economic studies. One US study reported that a classroom lesson resulted in a positive change in sun safety behaviour and reduced treatment costs (in terms of cancers averted) compared to no intervention (Kyle, 2008).

Economic analysis report 1

Three types of intervention were modelled:

It was only possible to develop a causal chain between the intermediate outcomes arising from the home‑based intervention and the prevention of skin cancer and thus estimate a cost per quality‑adjusted life year (QALY).

For the school and university‑based interventions, it was not possible to complete the causal chain. However, it was possible to give a reasonable estimate of the cost per participant and a threshold analysis was undertaken to assess the change in exposure to ultraviolet light that would be needed to make them cost saving or cost effective. Thresholds of £20,000 and £30,000 per QALY were used.

The estimated cost per QALY for the home‑based intervention was £6700 (if each handbook cost 90 pence). However, there is considerable uncertainty in these results. The threshold analysis suggests that, if a reasonably inexpensive intervention can achieve similar changes in behaviour in less sunnier climates, then it is likely to be cost effective. (That is, in terms of the benefits of reducing the incidence of skin cancer.)

Review 4

No economic studies were found on the provision of shade or the provision of resources only. One study on the cost effectiveness of a multi‑component intervention was identified. The intervention took place in a community setting.

Economic analysis report 2

An economic model was developed to estimate the cost effectiveness of adding shade structures to an existing environment and multi‑component interventions in six different settings. In addition, a break‑even analysis was undertaken to estimate the effect size needed to ensure a mass‑media intervention would be cost effective.

The analysis indicates that none of the interventions modelled are cost effective. The estimated incremental cost‑effectiveness ratio (ICER) for the six multi‑component interventions far exceeded the £20,000 to £30,000 threshold.

However, if the cost of providing shade could be reduced by incorporating it into the design of new buildings and other environments from the outset, this could significantly improve the ICER. For example, when the cost per person was reduced from £1.82 to £0.015 in the threshold analysis, the cost per QALY was just above the £20k threshold (£20,180). (This assumes these shaded areas would be used in similar way in the UK, where the climate is cooler.)

The breakeven analysis for a mass‑media campaign indicates that for a 'low' cost campaign to be cost‑effective, it would have to increase the percentage of people always using sunscreen by 2 points. For a 'high' cost campaign, there would have to be an increase of 6.6 percentage points. (Note: in 2009, a low-cost campaign would have cost an estimated £0.0028 per person per year, compared to £0.0093 per person per year for a high-cost campaign.)

The main lesson learned from such analysis is that interventions need to have a very low unit cost to be cost effective.