Special Issue "Sunbathing Habits and Skin Cancer"

Guest Editor
Dr. Magnus Falk
Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, S-581 85 Linköping, Sweden
E-Mail: magnus.falk@lio.se
Phone: +46 10 1035337
Interests: skin cancer prevention, and affecting health behaviours, in primary care; photodermatology

Guest Editor
Prof. Dr. Christopher David Anderson
Department of Dermatology, University Hospital, 581 85 Linköping, Sweden
E-Mail: chris.anderson@lio.se
Phone: +46 101031750

Dear Colleagues,

The evidence that sunbathing is associated to skin cancer is overwhelming. Cultural differences in the desire of a population to seek out the sun, differs, being more pronounced amongst paler populations in moderate to colder climates. Within a population sun seeking habit varies with age, gender, geographical location and the individual’s perceived risk status influencing behaviour and attitudes. As well as risk groups for skin cancer development such as sun sensitive skin type and familial or individual history of melanoma it is generally accepted that exaggerated sun exposure, most often in the form of recreational exposure such as sun bathing, should be avoided during childhood. Information about risk and methods for reducing sun exposure are keys to changing sun exposure habits and attitudes. Information campaigns need to be factual and effective. Evaluations of the outcome of preventive campaigns, whether they be directed to specific groups or to the general public, need to be performed. When total avoidance of sunlight is not possible (or desired), sunscreens and protective clothing are alternatives in the last line of defence in an activity (sunbathing) which is often enjoyed but is potentially dangerous in the long term. Moving behavioural patterns toward more controlled exposure to light including the small amounts of UV necessary to maintain adequate levels of vitamin-D, is an important public health issue.

Prof. Dr. Christopher David Anderson
Dr. Magnus Falk
Guest Editors

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Pascale Quatresooz, Claudine Piérard-Franchimont and Gérald E. Piérard Article: The Skin Ivory Spot. A Possible Indicator for Skinfield Photo-Carcinogenesis in Recreational Sunbed Addicts Int. J. Environ. Res. Public Health 2012, 9(2), 362-369; doi:10.3390/ijerph9020362 Received: 10 January 2012; in revised form: 16 January 2012 / Accepted: 17 January 2012 / Published: 25 January 2012 Show/Hide Abstract | Download PDF Full-text (764 KB) | Download XML Full-text Abstract: Introduction: For a decade or so, artificial sources of restricted light wavelengths, particularly sunbeds, have progressively gained popularity among adolescents and young adults. Warnings were raised focusing on the risk of accelerated photoaging and photocarcinogenesis. The ULEV (ultraviolet light-enhanced visualization) method is a convenient noninvasive way identifying subtle pigmentary changes presenting as a mottled subclinical melanoderma (MSM). Of note, rare spotty amelanotic macules presenting as skin ivory spots (SIS) was reported on any part of the body. Subjects and method: This work is the first attempt at evaluating the changes in the MSM and SIS spots developed on the skin of 33 phototype III young women designated as avid users involved in frequent exposures to sunshine and sunbeds for lifestyle purposes for a duration of at least 120 months. Results: MSM was markedly heterogeneous and was distinctly obvious in the majority of adepts of frequent natural and artificial photoexposures. SIS was particularly developed in subjects presenting with severe MSM patterns. Discussion: MSM and SIS are more severe in subjects frequently exposed to sunbeds and sun exposures. These signs possibly represent a risk marker for field photocarcinogenesis.

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Sheleigh Lawler, Liane McDermott, David O’Riordan, Kym Spathonis, Elizabeth Eakin, Evie Leslie, Cindy Gallois, Nadine Berndt and Neville Owen Article: Relationships of Sun-Protection Habit Strength with Sunscreen Use During Outdoor Sport and Physical Activity Int. J. Environ. Res. Public Health 2012, 9(3), 916-923; doi:10.3390/ijerph9030916 Received: 25 January 2012; in revised form: 2 March 2012 / Accepted: 5 March 2012 / Published: 15 March 2012 Show/Hide Abstract | Download PDF Full-text (232 KB) | Download XML Full-text Abstract: The objective of this cross-sectional questionnaire study was to assess associations of a self-report index of sun protection habit strength with sunscreen use in sporting environments and outdoor physical activity. Participants (n = 234) in field hockey, soccer, tennis and surf sports in Queensland, Australia, completed a self-administered survey on sun protection during organized sport, and during general outdoor physical activity during 2005/2006. The sun protection habit strength index was dichotomized into two categories. Multinomial logistic regression analyses assessed the associations of low versus high sun protection habit strength with three categories of sunscreen use (no or rare use; inadequate use; and adequate use). Compared to participants with low sun protection habit strength, those with high sun protection habit strength had significantly greater odds of any sunscreen use during organized sport and during general outdoor physical activity. This association was strongest for adequate sunscreen use in both settings. In conclusion, this study suggests that the measure of sun protection habit strength is a potentially useful assessment tool for future sun protection studies.

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Mary L. Greaney, Elaine Puleo, Alan C. Geller, Stephanie W. Hu, Andrew E. Werchniak, Susan DeCristofaro and Karen M. Emmons Article: Patient Follow-Up After Participating in a Beach-Based Skin Cancer Screening Program Int. J. Environ. Res. Public Health 2012, 9(5), 1836-1845; doi:10.3390/ijerph9051836 Received: 16 March 2012; in revised form: 25 April 2012 / Accepted: 2 May 2012 / Published: 10 May 2012 Show/Hide Abstract | Download PDF Full-text (140 KB) | Download XML Full-text Abstract: Many skin cancer screenings occur in non-traditional community settings, with the beach being an important setting due to beachgoers being at high risk for skin cancer. This study is a secondary analysis of data from a randomized trial of a skin cancer intervention in which participants (n = 312) had a full-body skin examination by a clinician and received a presumptive diagnosis (abnormal finding, no abnormal finding). Participants’ pursuit of follow-up was assessed post-intervention (n = 283). Analyses examined: (1) participant’s recall of screening results; and (2) whether cognitive and behavioral variables were associated with follow-up being as advised. Just 12% of participants (36/312) did not correctly recall the results of their skin examination. One-third (33%, 93/283) of participants’ follow-up was classified as being not as advised (recommend follow-up not pursued, unadvised follow-up pursued). Among participants whose follow-up was not as advised, 71% (66/93) did not seek recommended care. None of the measured behavioral and cognitive variables were significantly associated with recall of screening examination results or whether follow-up was as advised. Research is needed to determine what factors are associated with follow-up being as advised and to develop messages that increase receipt of advised follow-up care.

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Daniel J. O’Keefe and Daisy Wu Review: Gain-Framed Messages Do Not Motivate Sun Protection: A Meta-Analytic Review of Randomized Trials Comparing Gain-Framed and Loss-Framed Appeals for Promoting Skin Cancer Prevention Int. J. Environ. Res. Public Health 2012, 9(6), 2121-2133; doi:10.3390/ijerph9062121 Received: 18 April 2012; in revised form: 30 May 2012 / Accepted: 30 May 2012 / Published: 5 June 2012 Show/Hide Abstract | Download PDF Full-text (109 KB) | Download XML Full-text Abstract: Persuading people to undertake actions to prevent skin cancer is an important public health challenge. A number of studies have compared the effectiveness of gain-framed and loss-framed appeals in this domain, often expecting gain-framed appeals to be more persuasive. A meta-analytic review (k = 33, N = 4,168), however, finds no significant difference in the persuasiveness of gain- and loss-framed appeals for encouraging skin cancer prevention. This conclusion is unaffected by differences in the specific protective action advocated or by differences in the kind of outcomes invoked. But the results offer an intimation that men might be more susceptible to framing variations in this domain—with loss-framed appeals potentially having a persuasive advantage.

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Carolyn J. Heckman, Susan Darlow, Jessye Cohen-Filipic, Jacqueline D. Kloss, Sharon L. Manne, Teja Munshi and Clifford S. Perlis Article: Psychosocial Correlates of Sunburn among Young Adult Women Int. J. Environ. Res. Public Health 2012, 9(6), 2241-2251; doi:10.3390/ijerph9062241 Received: 28 April 2012; in revised form: 25 May 2012 / Accepted: 8 June 2012 / Published: 18 June 2012 Show/Hide Abstract | Download PDF Full-text (121 KB) | Download XML Full-text Abstract: Skin cancer is an increasingly common disease, particularly among young adult women. Sunburn early in life is a risk factor for skin cancer. Few studies have reported on psychosocial correlates of sunburn. The current study consisted of an online survey of undergraduate women from a university in the northeastern part of the USA. A logistic regression demonstrated that young women who reported a history of four or more sunburns were significantly more likely to report fair skin, higher perceived susceptibility to skin cancer, greater perceived benefits of tanning (e.g., appearance enhancement), lower perceived control over skin protection, and more frequent sunscreen use. Sunbathing was not associated with a greater number of sunburns. These results suggest that young women who sunburn more often possess other skin cancer risk factors, are aware of their susceptibility to skin cancer, and try to use sunscreen, but feel limited control over their skin protection behavior and are not less likely to sunbathe than others. Therefore, interventions are needed to assist high risk young women in asserting more control over their sun protection behavior and perhaps improve the effectiveness of the sunscreen or other skin protection methods they do employ.

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Hélène Sancho-Garnier, Bruno Pereira and Pierre Césarini Article: A Cluster Randomized Trial to Evaluate a Health Education Programme “Living with Sun at School” Int. J. Environ. Res. Public Health 2012, 9(7), 2345-2361; doi:10.3390/ijerph9072345 Received: 4 May 2012; in revised form: 13 June 2012 / Accepted: 20 June 2012 / Published: 2 July 2012 Show/Hide Abstract | Download PDF Full-text (154 KB) | Download XML Full-text Abstract: Over-exposure to sunlight increases the risk of skin cancers, particularly when exposure occurs during childhood. School teachers can play an active role in providing an education programme that can help prevent this. “Living with the Sun,” (LWS) is a sun safety education program for school children based on a handy guide for classroom activities designed to improve children’s knowledge, but moreover to positively modify their sun safety attitudes and behaviours. The goal of our study was to determine the effectiveness of this programme by examining children’s knowledge, attitude and sun exposure behaviours prior to and after the completion of the programme. We carried out a cluster randomised trial in which the classes were randomly assigned to one of two groups; one using the LWS programme and another that didn’t, serving as the control. Data was collected before completion of the programme and an additional three times in the year after completion. The 70 participating classes (1,365 schoolchildren) were distributed throughout France. Statistical analysis confirmed that knowledge of sun risk increased significantly in the LWS classes (p < 0.001). Both groups positively changed their attitudes when considering the best sun protection, but the LWS group proved to consistently be more convinced (p = 0.04). After the summer holidays, differences between the two groups decreased throughout the year but stayed globally significant. We also observed some significant behaviour modification during the holidays. For instance, the LWS group applied sunscreen more frequently than the control group, and were more likely to wear a hat (72% versus 59%) and use a sun umbrella on the beach (75% versus 64%).

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Bang Hyun Kim, Karen Glanz and Eric J. Nehl Article: Vitamin D Beliefs and Associations with Sunburns, Sun Exposure, and Sun Protection Int. J. Environ. Res. Public Health 2012, 9(7), 2386-2395; doi:10.3390/ijerph9072386 Received: 30 April 2012; in revised form: 12 June 2012 / Accepted: 28 June 2012 / Published: 4 July 2012 Show/Hide Abstract | Download PDF Full-text (56 KB) | Download XML Full-text Abstract: The main objective of this study was to examine certain beliefs about vitamin D and associations with sun exposure, sun protection behaviors, and sunburns. A total of 3,922 lifeguards, pool managers, and parents completed a survey in 2006 about beliefs regarding vitamin D and sun-related behaviors. Multivariate ordinal regression analyses and linear regression analysis were used to examine associations of beliefs and other variables. Results revealed that Non-Caucasian lifeguards and pool managers were less likely to agree that they needed to go out in the sun to get enough vitamin D. Lifeguards and parents who were non-Caucasian were less likely to report that sunlight helped the body to produce vitamin D. A stronger belief about the need to go out in the sun to get enough vitamin D predicted more sun exposure for lifeguards. For parents, a stronger belief that they can get enough vitamin D from foods predicted greater sun protection and a stronger belief that sunlight helps the body produce vitamin D predicted lower sun exposure. This study provides information regarding vitamin D beliefs and their association with certain sun related behaviors across different demographic groups that can inform education efforts about vitamin D and sun protection.

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Title: Patient Follow-Up after Participating in a Beach-Based Skin Cancer Screening Program
Authors: Mary L. Greaney ^1,*, Elaine Puleo ², Alan C. Geller ³, Stephanie W. Hu ⁴, Andrew E. Werchniak ⁵, Susan DeCristofaro ⁶ and Karen M. Emmons ⁷
Affiliations: ¹ Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, MA, 02115, USA; E-Mail: mary_greaney@dfci.harvard.edu
² Department of Public Health, University of Massachusetts, 425 Arnold House, Amherst, MA, 01003-9304 USA; E-Mail: epuleo@schoolph.umass.edu
³ Department of Society, Human Development & Health, Harvard School of Public Health,  677 Huntington Avenue Boston, MA 02115, USA; E-Mail: AGELLER@hsph.harvard.edu
⁴ New York University Medical Center, New York, NY, 10016, USA; E-Mail: stephaniewhu@gmail.com
⁵ Department of Dermatology, Brigham and Women's Hospital, 221 Longwood AvenueBoston, MA 02115, USA; E-Mail: AWERCHNIAK@PARTNERS.ORG
⁶ Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 , USA; E-Mail: Susan_DeCristofaro@dfci.harvard.edu
⁷ Department of Society, Human Development & Health, Harvard School of Public Health, 677 Huntington Avenue · Boston, MA 02115, & Center for Community-Based Research, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; E-Mail: Karen_M_Emmons@dfci.harvard.edu
Abstract: Many skin cancer screenings occur in non-traditional community settings, with the beach being an important setting due to beachgoers being at high risk for skin cancer. This study is a secondary analysis of data from a randomized trial of a skin cancer intervention in which participants (n=312) had a full-body skin examination by a clinician and received a presumptive diagnosis (abnormal finding, no abnormal finding). Participants’ pursuit of follow-up was assessed post-intervention (n=283). Analyses examined: 1) participant’s recall of screening results; and 2) whether cognitive and behavioral variables were associated with follow-up being as advised. Just 12% of participants (36/312) did not correctly recall the results of their skin examination. One-third (33%, 93/283) of participants’ follow-up was classified as being not as advised (recommend follow-up not pursued, unadvised follow-up pursued). Among participants whose follow-up was not as advised, 71% (66/93) did not seek recommended care. None of the measured behavioral and cognitive variables were significantly associated with recall of screening examination results or whether follow-up was as advised. Research is needed to determine what factors are associated with follow-up being as advised and to develop messages that increase receipt of advised follow-up care.
Keywords: cancer screening; skin cancer prevention; skin examinations; sun protection

Title: Evaluation of the action “Living With Sun at school”: a health education program for solar prevention
Authors: H. Sancho-Garnier ¹, B. Pereira ² and P. Cesarini ³
Affiliation: ¹ CRLC Val d’Aurelle, Prevention and Epidemiology Dept Epidaure, Montpellier, France
² CHU Clermont-Ferrand,France
³ Sécurité solaire, Paris, France
Abstract: Background: Overexposure to sunlight increases the risk of skin cancers, cataracts, and age-related macular degeneration, particularly when exposure occurs during childhood. School teachers have the opportunity to play an active role in providing prevention advice. “Living with the Sun,” (LWS) is a new sun safety education program for elementary schoolchildren created in 2006 by an astrophysicist, a communications specialist, and a primary school teacher. It called for teachers to lead 10 workshops for 9- to 12-year-olds pupils during the last three months of the school year. The created tool is a teaching guide filled with classroom activities designed to improve children’s scientific knowledge and positively modify their sun safety attitudes and behaviour. Objectives: Research in epidemiology aims to improve the effectiveness of treatments but also of preventive interventions on risky behaviours such as excessive exposure to the sun. The goal was to determine the effectiveness of this preventive programme in increasing schoolchildren’s knowledge about sun exposure, positively modifying their sun-protective behaviour. Methods: We carried out a cluster randomised trial in which the classes, rather than individuals, were randomly assigned to one of two groups: one using the LWS program and one not (the latter serving as control group).. Cluster randomised trials are valuable in the evaluation of interventions including school classes, families, and villages. Existing relationships between individuals in the group (who have some similarities and influence each other), have to be examined and eventually controlled. Data regarding the children’s knowledge, attitudes, and behaviour were collected both before and then three times after completion of the program (immediately, after the summer holidays, and one year later). The 70 participating classes, consisting of 1,365 schoolchildren with a mean age of 9.9 years, were distributed all over France. The statistical analysis is conducted with mixed effects linear regression extensions accounting for dependencies among cluster members. Results: Statistical analysis confirmed that knowledge on sun risk increased significantly in the LWS classes ( p<0.001); Children’s age, skin colour, and predisposition to sunburn (skin type) also affected their scores. After the summer holidays, differences between the two groups decreased a little. Children in the LWS classes were more likely than the control group to state that it was necessary to be protected against the sun, especially in the mountains (OR=3.01, 95%CI[2.01:4.87]), and that the use of sunscreen was a good way to avoid skin damages (OR=1.54, 95%CI[1.05:2.27]). We also observed some significant behaviour modification during the holidays: the LWS group applied sunscreen one and a half times more frequently than the control group, and were more likely to wear a hat (72% versus 59%) and use a sun umbrella on the beach (75 % versus 64 %). Conclusion: The approach used in the LWS program appears to produce a significant increase in knowledge and a positive modification of children’s sun-related attitudes and behaviour for at least 6-12 months.