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The number of new cases of melanoma skin cancer increased between 1975 and 2006, with an estimated number of 68,720 new cases in 2009. More than one million people are diagnosed with basal cell and squamous cell (non-melanoma) skin cancer in the United States every year. Basal and squamous cell cancers are the two most common types of skin cancers in the country. Although 40–50 percent of Americans who live to age 65 will have non-melanoma at least once, most of these cancers, as well as melanoma skin cancers, can be prevented. Studies suggest that reducing unprotected exposure to the sun and artificial light from tanning beds, tanning booths, and sun lamps can lower the risk of skin cancer. Avoiding sunburns, intermittent high-intensity exposure, and other damage from these sources—especially in children and teens—reduces the chances of getting melanoma skin cancer. All of these types of skin cancers are most common in light-skinned people, although they also occur in people with darker skin.
Percentage of adults aged 18 and older who reported that they usually or always practice at least one of three sun protection behaviors (using sunscreen, wearing protective clothing, or seeking shade) when going outside on a sunny day for more than one hour.
Beginning in 2005, the question on hat use (as part of protective clothing) was supplemented and modified to more accurately distinguish baseball caps (which do not fully protect the face, neck, and ears) from other types of fully protective hats. Graphic illustrations of different hats were used, and respondents were asked a separate question about baseball cap and sun visor use.
The National Health Interview Survey Cancer Control Supplement data in 2005 for the first time tracked indoor tanning use by both adults and adolescents. The percentage of teens aged 14–17 years who have used an indoor tanning device one or more times during the past 12 months is reported here. This was reported by a knowledgeable adult household respondent. Self-reports of use of the same devices by adults aged 18 years and older are also tracked.
From 1992 to 2008, there were some decreases and increases in the percentage of adults reporting use of one or more sun protective behaviors. Overall, by 2008, reporting of one or more sun protective behaviors in which the sun protective clothing component was more loosely defined (i.e., including partially protective baseball caps and sun visors) increased about 12 percentage points from 1992, when the percentage was 53.7. Also, the percentage of those reporting one or more sun protective behaviors in 2008 still represents a 4 percentage point increase over the 1992 value even after differentiating the use of fully sun protective hats from the use of baseball caps in 2005.
Protective clothing: The percentage of people who usually or always wear at least one sun protective article of clothing (fully sun protective hat or long-sleeved shirt) increased over the last period of 2005 to 2008.
Women’s practices of these behaviors were stable from 2000 to 2005 and then rose during the most recent period of 2005 to 2008. Men’s practices of these behaviors decreased between 2003 and 2005, likely as a result of the adjustment in not counting baseball caps as fully protective. Men continue to show a far greater use of baseball caps for protection than the more fully protective type of hat that shades the ears, face, and neck. Women wear a fully protective hat more often than men do. There are no differences in trend by race/ethnicity, age, or poverty level.
Shade: The percentage of people who usually seek shade has shown little change overall, beginning with 32.3 percent in 1992. Similar trend patterns are seen among men and women, among various race/ethnicity groups, among younger and older adults, and by poverty level.
Sunscreen: Overall, the percentage of people who usually use sunscreen rose slightly from 1992 to 2008. There was only one statistically significant period of falling, between 2003 and 2005. The level of sun protective factor (SPF), which is more in line with the intent of the Healthy People 2010 goal for sunscreen use, was tracked beginning in 2000. There was a statistically significant rise between 2000 and 2008 for both use of any sunscreen and use of sunscreen with the recommended SPF of 15 or higher. The latter trend appears steeper, suggesting greater compliance with SPF guidelines.
Trends at first appear similar for both males and females except that females had a greater increase in sun protective behaviors over the period than did males. However, further interpretation by gender and age reveals the greatest increases for 18–24-year-old females and the least change for 18–24-year-old males. Non-Hispanic Whites show the greatest increase among races/ethnicities examined.
Indoor tanning: There was an increase in adult indoor tanning among both men and women from 2005 to 2008. There was a fall in this practice among teens between the ages of 14 to 17 years of age. This decrease was significant among females.
Sun protective behaviors: In 2008, 57.6 percent of adults said they usually or always protected themselves from the sun by practicing at least one of three sun protective behaviors:
Only 44.5 percent of young adults aged 18–24 reported usually or always protecting themselves from the sun, whereas 59.5 percent of those 25 years of age and older reported usually or always protecting themselves. Among men aged 18 years and older, only 48.2 percent reported usually or always protecting themselves from the sun, in contrast to 66.7 percent of women aged 18 years and older. Women aged 25 years and older were the subgroup with the highest use of one or more sun protective behaviors (68.4 percent).
57.2 percent of non-Hispanic Whites, 55.1 percent of non-Hispanic Blacks, and 60.5 percent of Hispanics usually use some form of sun protection. Among those whose income is less than 200 percent of the poverty level, 55.4 percent use some form of sun protection. Among those with higher incomes, 58.2 percent use some form of sun protection.
Indoor tanning: In 2008, 15.2 percent of adults 18 years of age and older (12.0 percent of males and 18.3 percent of females) used indoor tanning devices in the past 12 months. Those using indoor tanning devices were primarily non-Hispanic Whites (17.8 percent), followed by Hispanics (11.0 percent), and then non-Hispanic Blacks (9.0 percent). Although 16.2 percent of those with incomes more than 200 percent of the poverty level used these devices, 12.9 percent of those within 200 percent of the poverty level also used these devices.
In 2008, nearly 6 percent of those aged 14 to 17 years used tanning devices during the past 12 months. Girls’ use (10.2 percent) of such devices was ten times more than boys’ use (1.1 percent). Use among non-Hispanic Whites was 8.6 percent, while the use of these devices was 1.4 percent among Hispanics and 0.4 percent among non-Hispanic Blacks. Teen use was highest among non-Hispanic White girls with an estimate of 16 percent.
Increase to 75 percent the proportion of adults who usually or always apply sunscreen with an SPF of 15 or higher, wear protective clothing, or seek shade.
Younger adults and men of any age are less likely to protect themselves from the sun. However, females seek shade far less than males. Adults with incomes below 200 percent of the poverty level are less likely to use sunscreen. Young adult women are most likely to get too much exposure to artificial light through indoor tanning.
In general, increased exposure to the sun—especially without adequate use of sunscreen and protective clothing—increases the chances of getting skin cancer. Recently, however, the competing need for vitamin D for bone health, general health, and possibly helping to prevent certain other forms of cancer has been raised. Vitamin D is most efficiently produced through exposure to sunlight, but it can also be obtained through the diet, primarily through fortified foods and supplementation.
Key messages of the First North American Conference on UV, Vitamin D and Health, held on March 8, 2006, and a Position Statement released on June 16, 2007, by the Cancer Council Australia along with several other organizations include guidelines for when sun protection is required. These two sets of guidelines still conform with the present World Health Organization (WHO) guidelines that recommend sun protection when the UV index is 3 (moderate) or higher. The First North American Conference on UV, Vitamin D and Health further noted, "The known risks associated with unprotected UVB exposure must be weighed against its benefits as a source of vitamin D. For example, it is possible that just a few minutes a day of unprotected sun exposure will increase vitamin D status, but for some may also increase the risk of skin damage. Factors such as age, diet, skin pigmentation, geographic location and intensity of the sun will affect the amount of sun exposure needed to produce adequate vitamin D. More research is needed in this area before any more specific recommendations can be made."
In 2007, two National Institutes of Health—sponsored conferences were held, and an NCI study and an American Institute for Cancer Research (AICR) World Cancer Research Fund (WCRF) Expert Panel report were published with information pertaining to the effects of vitamin D on cancer and other diseases. The NCI study found a protective effect of vitamin D status on colorectal cancer mortality, but no effect on total cancer mortality. An editorial by co-sponsors of one of the NIH conferences cautioned that although vitamin D likely has many health benefits besides its benefits for bone health, health professionals and the public should not rush to judgment that vitamin D is a solution for good health. The AICR-WCRF report concluded that their review of cohort studies provided limited evidence suggesting that foods containing vitamin D or vitamin D status are protective against colorectal cancer. Most recently, a 2008 IARC Working Group report, “Vitamin D and Cancer,” concluded that hypotheses on vitamin D status and colorectal cancer, cardiovascular diseases, and all-cause mortality should be tested in appropriately designed randomized controlled trials. They cautioned against hastily recommending widespread supplementation of vitamin D, given the lack of knowledge of its long-term side effects and past experience from studies of vitamins, antioxidants, and hormones.
Some research suggests that people often apply less than an adequate amount of sunscreen and fail to reapply it appropriately. This, coupled with research showing that those who use sunscreen for intentional sun exposure tend to increase their time spent in the sun, is likely to result in more skin damage rather than sun protection. A recent Australian randomized clinical trial, the Nambour Skin Cancer Study, showed that 4.5 years of daily sunscreen application resulted in a statistically significant 38 percent reduction in incidence of squamous cell carcinoma, compared with discretionary use. Although an additional 8 years of follow-up did not yield a statistically significant difference for basal cell carcinoma (BCC) with daily sunscreen use, the late follow-up period showed a non-significant 25 percent decrease in BCC tumor incidence in the former sunscreen treatment group with confidence intervals narrowing.
The Food and Drug Administration (FDA) has pending regulation to improve labeling on sunscreen about UVA and UVB, because current labeling misleads the public about the protection they are getting from the sun. For example, a sunscreen must contain ingredients that block both UVA and UVB sun rays. Also, the SPF factor relates only to blockage of UVB rays, and not to the sunscreen's ability to block UVA.
According to industry estimates in the United States, there are roughly 20,000 professional indoor tanning salons. In addition, 15,000 to 20,000 sites, such as health clubs, spas, video stores, and beauty salons, have one or two tanning units. In most states, indoor tanning facilities are unregulated, with no age restriction for usage. Adolescence and childhood are particularly vulnerable periods for future development of skin cancer. WHO recommends that access to tanning beds be restricted for those under 18 years of age. As of June 30, 2008, 21 states had enacted laws restricting minors’ access to tanning facilities. Of these states, four have enacted bans: California, New Jersey, and New York prohibit minors under 14 years of age from using tanning facilities, and Wisconsin prohibits use by minors under 16 years of age (State Cancer Legislative Database, August 2008 Fact Sheet on Skin Cancers). Adults could also be protected by future FDA regulations proposed for indoor tanning equipment/facilities, given the increase shown for those aged 25 years and older.
Pichon et al. recently published data from the U.S. City 100 Project showing less than 30 percent compliance with FDA’s recommended practices for indoor tanning sessions. These data highlight the need for enforceable requirements. Bans on minors’ access to tanning facilities may both reduce youth access in a direct way, and also more forcefully educate parents about the dangers of indoor tanning. Another report from the U.S. City 100 Project found that there was an average of 42 salons per city. This exceeded the average number of Starbucks and McDonald’s per city. The density of tanning salons highlights the importance of regulation of this fast-growing industry so that we do not see further increases in the rate of melanoma incidence.
Data presented in this section showing a decline in teen indoor tanning prevalence over a 3-year period are loosely consistent with the overall increase in localities and states that have enacted laws restricting indoor tanning for minors. Further direct analysis of this relationship would be useful in understanding the exact nature of the type of restriction, enforcement, and subsequent use of indoor tanning by youth. The finding from Australia by Makin et al. that the states with the earliest and most comprehensive legislation to restrict the use of tanning facilities have seen the largest reduction in the number of tanning salons provides direct support for the relationship between legislation and demand for tanning facilities. The reduction in demand for tanning facilities yielding less indoor tanning exposure would be expected to ultimately result in less melanoma incidence, unless compensated for by direct sunlight exposure.