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ARTICLE |
a Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia
b DermatoEpidemiology Unit, VA Medical Center Providence, Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island
c Departments of Dermatology and Community Health, Brown University, Providence, Rhode Island
d Rollins School of Public Health, Emory University, Atlanta, Georgia
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. Cross-sectional telephone surveys of youth aged 11 to 18 years in 1998 (N = 1196) and in 2004 (N = 1613) were conducted using a 2-stage sampling process to draw population-based samples. The surveys asked identical questions about sun protection, number of sunburns experienced, and attitudes toward sun exposure. Time trends were evaluated using pooled logistic regression analysis.
RESULTS. In 2004, 69% of subjects reported having been sunburned during the summer, not significantly less than in 1998 (72%). There was a significant decrease in the percentage of those aged 11 to 15 years who reported sunburns and a nonsignificant increase among the 16- to 18-year-olds. The proportion of youth who reported regular sunscreen use increased significantly from 31% to 39%. Little change occurred in other recommended sun protection practices.
CONCLUSIONS. A small reduction in sunburn frequency and modest increases in sun protection practices were observed among youth between 1998 and 2004, despite widespread sun protection campaigns. Nevertheless, the decrease in sunburns among younger teens may be cause for optimism regarding future trends. Overall, there was rather limited progress in improving sun protection practices and reducing sunburns among US youth between 1998 and 2004.
Key Words: skin cancer • skin neoplasms prevention and control • sun exposure • sun protection • sunburn • sunscreen agents • adolescent • epidemiology • health surveys
Abbreviations: SPF 15+—sun protection factor 
15 • CI—confidence interval
More than 1 million cases of basal cell or squamous cell carcinoma and 62190 cases of invasive melanoma are expected in 2006 in the United States.1 Of these, only melanoma is included in cancer statistics published each year by US tumor registries. Although basal cell and squamous cell skin cancers (keratinocyte carcinomas) are highly treatable, they account for considerable morbidity and health care expenditures. Furthermore, the incidence of both melanoma1–3 and keratinocyte carcinoma4–6 have been increasing.
Extensive epidemiological and biological evidence implicates sun exposure as the principal cause of melanoma and keratinocyte carcinomas of the skin.7,8 An estimated 80% of all skin cancers are caused by UV solar radiation.8 Despite evidence that excessive sun exposure in childhood contributes to the risk of skin cancers later in life,9 sunburns, which are markers of intense UV exposure, remain common, especially among adolescents.10–12 Several recent studies also highlight the ongoing inadequacy of reported sun protection practices among adolescents.13–15
Most governmental and nongovernmental efforts to prevent skin cancer in the United States have sought to change the individual behaviors of parents and children,16–19 without a concomitant emphasis on sun protection policies, such as those used effectively in Australia.20 Furthermore, there have been no systematic efforts to assess the effectiveness of sun protection interventions in youth nationwide or to measure their changes in attitudes toward sun protection and tanning, despite the substantial disease burden caused by excessive sun exposure. This study compared the frequency of sunburns and attitudes and behaviors regarding sun protection in 2 nationally representative surveys of 11- to 18-year-olds conducted in 1998 and 2004.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Both surveys asked identical questions about sun protection behaviors, sunburn experiences, and sun protection attitudes. Trained interviewers administered the surveys using structured telephone questionnaires. Each interview took an average of 15 minutes to administer. Up to 14 attempts were made to reach the eligible participant. Initially, the interviewer spoke with the parent or guardian to complete a parent-specific survey and gather sociodemographic information and sun protection practices by the parent. Then the selected adolescent completed the interview. Quality control logs were maintained throughout the data collection period, and data entry error rates were low (<3%). Standard response rate formulas were used to calculate the screening, refusal, and response rates for both surveys.23 The screening rates were 
90% on both surveys; this indicates that a high percentage of the eligible population was successfully screened for age and household eligibility. The percentage of households in which a parent and child declined or the parent declined for both to participate was 25% in 1998 and 27% in 2004. These refusal rates seem high because a refusal could occur before the screening process began or at any time during the screening or interviewing process. The final response rates, defined as the percentage of the (possibly) eligible population who completed the interviews, were 58% in 1998 and 44% in 2004; the lower response rate in 2004 was affected by a larger proportion of telephone numbers with undetermined status (28%) as compared with the proportion of telephone numbers with undetermined status (ie, ring, no answer) in 1998 (13%). Participation rates in random-digit dialing surveys have been reported to range from 22% to 70%, with a median of 50%. In recent years, declines in response rates in random-digit dialing surveys have been reported.24 In this report, we focused the trend analysis only on the youth data, whereas analysis of parent data will be the subject of future reports.
Measures
Subjects were asked about their age, gender, and race, and a series of questions related to individuals' phenotypic susceptibility to the sun. A validated measure of sun sensitivity25 was used to categorize susceptibility to sun exposure based on 4 phenotypic characteristics: skin reaction after 1 hour of exposure to the summer sun (sensitivity to sunburn), skin reaction after repeated exposure to the summer sun (ease of skin's tanning ability), the natural color of the skin, and the natural color of the hair.
Subjects were asked 4 questions to determine the average number of hours per week spent outdoors between 10:00 AM and 4:00 PM on weekdays during the recent summer, the average number of hours per week spent outdoors between 10:00 AM and 4:00 PM on weekends during the recent summer, the average number of days in the past 12 months spent at the beach between 10:00 AM and 4:00 PM, and the number of days in the past 12 months spent at an outdoor pool between 10:00 AM and 4:00 PM.
Subjects were asked whether they experienced a sunburn (defined as any reddening of the skin lasting 12 hours, received from being out in the sun) during the recent summer and, if so, the number of total sunburns experienced during the summer. A follow-up question asked those who experienced sunburns whether they had taken any measures of sun protection before getting their most serious sunburn in the summer; response options included: wearing protective clothing, hats, or sunglasses; applying sunscreen; or staying in the shade.
A series of questions were used to ascertain the frequency of practicing various recommended sun-safe behaviors when going outdoors on a very sunny day during the summer for >1 hour. The sun protective practices included staying in the shade or under an umbrella, wearing sunglasses, wearing a wide-brimmed hat, wearing protective clothing, such as a long-sleeved shirt or long pants, applying sunscreen lotion, and applying a sunscreen with a sun protection factor 15 (SPF 15+) when at the beach or pool. Response options for these questions used a 5-point Likert scale ranging from "always" to "never." The behavioral outcomes were dichotomized into regular (reported practicing the behavior always or often) versus nonregular (reported practicing the behavior sometime, rarely, or never).
Subjects were asked a series of items using a 4-point Likert scale ranging from strongly agree to strongly disagree reflecting attitudes about sun exposure and tanning appeal. Attitudes toward sun protection included 4 items: "protecting my skin from the sun is an easy way to stay healthy," "using sunscreen lotion allows me to enjoy the outdoors with less worry," "spending time in the sun without any protection can increase my chances of developing cancer," and "my skin won't wrinkle as fast if I spend less time in the sun" (our sun protection attitude index is a summary measure of these 4 items and has a reliability coefficient Cronbach 
=.62). Two other statements reflect attitudes related to outdoor sun exposure and may be considered as separate potential barriers against reducing sun exposure: "the sun feels good on my skin" and "avoiding the sun takes the fun out of being outdoors." These did not correlate with our sun protection index and were considered separately. The tanning preference factor reflects an underlying attitudinal preference for tan, and it included 2 items: "I feel healthy when I have a nice tan" and "I look better when I have a tan" (reliability coefficient Cronbach = .69).
Statistical Analysis
For both surveys, sampling weights were calculated that take into account unequal probabilities of selection because of sample design, nonresponse, and poststratification. Data management was conducted using SAS software, version 9.0 (SAS Institute, Cary, NC).26 SEs were calculated with SUDAAN software, version 9.0 (Research Triangle Institute, Research Triangle Park, NC),27 to account for the complex sample design; these were applied to calculate weighted estimates to make results representative of the noninstitutionalized population of US youth aged 11 to 18 years old. Using the weighted corresponding estimates and SEs in each survey year, we present the weighted differences (change in the estimates between 2004 and 1998) and 95% confidence intervals (CIs) for the change in the estimates for the measures of sun safe practices, sunburns, and attitudes toward sun exposure protection and tanning. In addition to categorical and univariate analysis of 
2 and t tests, we also tested for the statistical significance of overall time trends (change in the estimates between 1998 and 2004) with pooled logistic regression analysis using dichotomous outcomes, and the key predictor was time (2004 = 1 and 1998 = 0); these models also tested for significant potential interactions between time and selected covariates (age, gender, race, and sun sensitivity).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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8% among 11- to 13-year-olds and 9% in 14- to 15-year-olds (P < .01; Table 2). In a multivariate analysis controlling for confounders (age, gender, race, and sun sensitivity), we found a positive association between having had sunburns and regular use of sunscreen when going outdoors in the summer (data not shown). Among those who sunburned, the most common reported measure of protection before experiencing the most serious sunburn of the summer was application of sunscreen, whereas other measures of sun protection were very infrequent (<2%). Compared with 1998 levels, the prevalence of wearing sunscreen before experiencing a serious sunburn increased significantly (overall, from 39% to 47%; P < .001; Table 2). During the 6-year period, there were larger trends that showed increases in the percentage of youth reporting sunscreen use before getting a serious sunburn among those aged 11 to 15 years, boys, and those with more sun-resistant skin traits and of nonwhite race (Table 2).
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5% in 2004). No measurable changes in these practices were observed between 1994 and 2004, except for an increase in the prevalence of regular use of long-sleeve shirts or long pants among white youth (P < .05; Table 3). Similar trends were observed when comparing regular (always or often) to always use (Table 3).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our study collected data from 2 time periods on multiple behavioral and attitudinal end points. We found that trends in US youth sun protection were mixed during the interval of 1998 to 2004. The prevalence of youth experiencing sunburns during the summer was high and generally stable between 1998 and 2004 (70% in 2004). However, there were significant trends of decreasing prevalence of sunburns among younger teens. It is likely that this age-specific trend may relate in part to greater parental influence in younger adolescents (as well as children), because several studies indicate that parental vigilance and parent's sun protection behaviors are related to greater sun protection practices and reduced likelihood of sunburn experiences in their children.13,32–35 Between 1998 and 2004, the prevalence of regularly practicing measures of sun protection were low, whereas opportunities for high (intermittent) UV exposure seem to have increased (ie, increased number of days spent at the beach). Interestingly, among older youth, we found a larger trend increase in the numbers of days spent at the beach than in younger youth (data not shown). However, we lack the information to determine whether the trend increase in the numbers of days spent at the beach is related to proximity to the beach, popularity of the beach as family vacation, or more affordable and frequent travel to beach by older youth. The beach setting, in particular, provides a greater opportunity for exposure to intense (intermittent) UV exposure and is associated with extended time of UV radiation exposure.36,37
We also found increasing trends in the proportion of youth who reported wearing sunscreen before getting their most serious sunburns and that regular use of sunscreen was independently associated with experiencing sunburn in the past summer, after adjusting for confounders. These findings, in parallel to our findings of an increasing trend in regular sunscreen use as described next, may suggest that sunscreen use is marker of excessive UV exposure and that, whereas intending to protect themselves from the sun, inadequate application of sunscreen (ie, not enough applied or certain areas of the body missed) or sunscreens degraded or washed off from swimming, sweating, or other activities may undermine the sunscreen efficacy for prevention of sunburns.38–40 Our findings showed very few improvements in trends for the regular (routine) practice of sun protection behaviors and in attitudinal preferences to tanning, whereas some trends in barriers to reduced sun exposure increased. Specifically, between 1998 and 2004, the only positive increases were for the regular use of sunscreens, and there was a slight and nonsignificant reduction (2%) in the prevalence of regular use of sunscreen with SPF 15+ when at the beach or pool (58% vs 56%). Sunscreen use continues to be the main form of protection from the sun practiced by youth. Our study found no changes, and the regular use of other sun protection measures (ie, protective clothing, seeking shade, and wearing sunglasses) was less prevalent. In particular, the regular use of wide-brimmed hats in this population was very infrequent. Research is needed to understand the reasons or barriers (eg, attitudes, norms, or contextual settings) related to the low adoption of such practices.
Modest but significant increases in the prevalence of youths' attitudes related to benefits of sun protection occurred between 1998 and 2004; youth in general seem to hold largely positive attitudes (knowledge-related benefits) toward sun protection (with the exception that knowledge levels about the effect of UV exposure and skin photograph-aging effects were moderate). Educational skin cancer prevention efforts in schools, outdoor aquatic settings, and media campaigns may have contributed to these improvements in attitudes/knowledge during the 6-year period.16,18,19 In addition, although trends showed modest decreases, youths' tanning preferences continued to be prevalent, and barriers related to sun exposure ("sun feels good on my skin" and "avoiding the sun takes the fun out of being outdoors") increased during this period. This may suggest that skin cancer prevention efforts to change such attitudes may been (somewhat) less effective in youth or that other factors, such as social norms toward tanning, fashion trends, peer pressure, and the lack of policies to support sun-safe environments, may have been more influential so as to preclude changes in attitudes.41–45 Because such attitudes are determinants of sun exposure and sun protection behaviors,10,13–15,46–48 it is important to develop better educational messages and strategies targeted at youth.
There were several strengths and limitations in this study. The surveys used the same instruments, which include questions for multiple behavior and attitude end points, and the same probability sampling methodology to allow for generalizing estimates to the entire population of US youth aged 11 to 18 years. However, the telephone survey methodology limited the generalizability of results to persons with a telephone (95% of US households).49 Particularly in the most recent survey, a substantial proportion of households were not reached despite multiple attempts, or selected subjects did not complete the telephone interview, and, thus, a potential for unmeasured bias may be present. The sampling design allowed for a representative sample of the US population, but certain low-frequency population subgroups were not well represented, because cost issues did not permit oversampling. We note that skin cancer is higher among the white-skinned population, a group that is well represented in these surveys. Data used in this study were based on self-reports and possibly subject to recall bias or social desirability bias. However, surveys were conducted in an anonymous fashion, and questions gathered information about recent events and experiences occurring either during the past summer (2–4 months before the date of interview) or within the last year.
Internationally, Australia has served as a model of a national (in scope) comprehensive skin cancer prevention program, which has used systematic ongoing population-based tracking of disease and behavioral end points.18,50,51 Early in the 1970s, Australia developed a national health care policy that made skin cancer prevention a public health priority; the Australian public educational campaigns known as Slip! Slop! Slap! (slip on a shirt, slop on some sunscreen, and slap on a hat) and the SunSmart program, the most recent national program, involved multipronged approaches in various settings (schools, worksites, and health care systems), as well as environmental supports and policies.20 In the United States, several broad-based national, state, and private skin cancer primary prevention efforts have been initiated, and most target primarily children.18,19,52–55 In light of our findings of mixed results on sun protection among US youth, there is a need to further expand efforts in targeting youth and to improve the effectiveness of these programs. In addition to the assessment of skin cancer disease trends, there is a need for concomitant surveillance activities to monitor sun protection practices and sunburn rates in youngsters (and in susceptible high-risk populations), thereby allowing the United States to measure success in skin cancer prevention and reduction in disease burden as incorporated in Objective 3.9 of the Healthy People 2010 goals.56
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Vilma Cokkinides, PhD, Department Epidemiology and Surveillance Research, American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251. E-mail: vcokkini{at}cancer.org
Other than the financial support for data collection, the funder did not play a role in the design and conduct of the study; data collection, management, analysis and interpretation of the data; or in the preparation, review, or approval of the article.
The American Cancer Society staff and coinvestigators were involved in 1 or more of the following: design and conduct of the study; data collection management; analysis and interpretation of the data; and preparation, review, and approval of the article.
Dr Cokkinides had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The ideas and opinions expressed herein are those of the authors.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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