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Sunburn and Sun Protective Behaviors Among Adults Aged 18–29 Years — United States, 2000–2010

Skin cancer is an important public health concern. Nonmelanoma skin cancers, comprised mainly of basal cell carcinoma and squamous cell carcinoma, are the most common malignancies in the United States (1). Melanoma, although less common, is the deadliest form of skin cancer (2). Both melanoma and nonmelanoma skin cancers can be disfiguring, negatively affect quality of life, and create economic burden (2,3). Furthermore, age-adjusted incidence rates of both have increased in recent years (1,4). Different patterns of sun exposure are associated with different types of skin cancer. Continuous, chronic sun exposure, such as that observed among outdoor workers is associated with squamous cell carcinoma (3). Intermittent exposure, such as recreational exposure, is associated with melanoma and basal cell carcinoma (3,5–7). Sunburn typically occurs after intermittent exposure, and the risk for melanoma increases with an increasing number of sunburns during all periods of life (4–7). Sunburn is more common among persons aged 18–29 years compared with older adults (8). To evaluate trends in sunburn and sun protective behaviors among persons aged 18–29 years, CDC and the National Cancer Institute analyzed data from the 2000, 2003, 2005, 2008, and 2010 National Health Interview Survey (NHIS). The results indicated that although protective behaviors such as sunscreen use, shade use, and wearing long clothing to the ankles have increased in recent years, sunburn prevalence remains high, with 50.1% of all adults and 65.6% of whites aged 18–29 years reporting at least one sunburn in the past 12 months. These results suggest that additional efforts are needed to identify and implement effective strategies targeting younger adults to improve their sun protective behaviors and prevent sunburn and ultimately skin cancer.

NHIS is an annual, cross-sectional survey of the civilian, noninstitutionalized U.S. population. Data about persons of all ages in the family are collected throughout the year. Interviews are conducted, mainly in person, with adults aged ≥18 years in each household, with follow-up by telephone when necessary. For this report, data from the NHIS cancer control supplement, which includes questions about sun protective behaviors and sunburn were used. Participants were asked how often they stay in the shade, wear a wide-brimmed hat, wear a long-sleeved shirt, and use sunscreen when outdoors in the sun; participants also were asked about the sun protection factor (SPF) of the sunscreen they usually use.

Beginning in 2005, three additions were made to the supplement. First, a question about wearing long clothing to the ankles was added. Second, a question asking "Is the SPF usually 1–14 or 15–50?" was added as a probe to decrease missing data on sunscreen SPF. Third, a question about wearing "a baseball cap or sun visor" (which do not provide sufficient protection) was inserted to precede the question regarding use of wide-brimmed hats (which do provide full sun protection to the face, ears, and neck), along with pictures of examples of wide-brimmed hats. This addition is thought to have improved the accuracy of wide-brimmed hat use estimates by reducing hat misclassification (9). Only estimates of wide-brimmed hat use during 2005, 2008, and 2010 are provided in this report. In 2000, 2005, and 2010, participants were asked the number of sunburns they had in the past 12 months. Final response rates for the sample adult component of NHIS each year were 72.1% (2000), 74.2% (2003), 69.0% (2005), 62.6% (2008), and 60.8% (2010).

Statistical software was used to account for the complex sampling design. Survey weights were used to produce nationally representative estimates. Analyses were limited to adults aged 18–29 years and age-adjusted to the 2000 U.S. population using the age groups 18–24 and 25–29 years. Estimates and 95% confidence intervals (CIs) for the percentage engaging in each of the sun protective behaviors "always" or "most of the time" and reporting one or more sunburns in the past 12 months were calculated for each year overall, by sex, and by race/ethnicity (white, black, other race, and Hispanic). Persons identified as Hispanic might be of any race; persons identified as white, black, or other race are all non-Hispanic.

Percentage differences were assessed using linear contrasts. Overall and subcategory trends were assessed using logistic regression analyses, with survey year included as a categorical covariate while controlling for age group. For all analyses, differences with p<0.05 were considered statistically significant.

Among women, using sunscreen (37.1%, CI = 34.7–39.5) and staying in the shade (34.9%, CI = 32.6–37.3) were the most common protective behaviors reported in 2010 (Figure 1). Wearing a wide-brimmed hat (3.8%, CI = 3.1–4.7) and wearing a long-sleeved shirt (5.3%, CI = 4.3–6.6) were the least common. Shade use ranged from 29.4% to 30.5% during 2000–2008 but increased to 34.9% in 2010 (p<0.05). Sunscreen use increased overall from 2000 to 2010 (p<0.01), and wearing long clothing to the ankles increased from 21.1% in 2005 to 25.7% in 2010 (p<0.01). Among women overall, no significant increases in wearing a long-sleeved shirt or wearing a wide-brimmed hat were observed over time. White women were less likely to report shade use (p<0.05 each year), and black women were less likely to report sunscreen use (p<0.01 each year) compared with persons of other races or Hispanics.

Among men, wearing long clothing to the ankles was the most common protective behavior reported in 2010 (32.9%, CI = 30.5–35.3), followed by staying in the shade (25.6%, CI = 23.4–27.9) and using sunscreen (15.6%, CI = 13.8–17.6) (Figure 2). Wearing a wide-brimmed hat (6.7%, CI = 5.6–8.0) and a long-sleeved shirt (7.6%, CI = 6.3–9.3) were least common. Shade use ranged from 18.5% to 20.6% during 2000–2008 but increased to 25.6% in 2010 (p<0.01). Wearing long clothing to the ankles increased from 28.3% in 2005 to 32.9% in 2010 (p<0.01). Changes in sunscreen use were inconsistent from 2000 to 2005, but use increased slightly from 13.6% in 2005 to 15.6% in 2010. Among men overall, no significant increases in wearing a long-sleeved shirt or wearing wide-brimmed hat were observed over time. No consistent differences in protective behaviors across racial/ethnic groups were observed.

In 2000, 2005, and 2010, sunburn prevalence was highest among whites (65.6% in 2010) and lowest among blacks (10.9% in 2010). The prevalence of sunburn among men (49.1% in 2010) was not significantly different from the prevalence among women (51.3% in 2010) overall or across racial/ethnic categories (Table). No significant differences in sunburn prevalence were observed in 2010 (50.1% overall) compared with 2000 (50.9% overall). However, sunburn prevalence decreased significantly from 2000 to 2005 (45.5% overall) before increasing in 2010 (Table).

Reported by

Anne M. Hartman, MS, MA, Frank M. Perna, EdD, PhD, Div Cancer Control and Population Sciences, National Cancer Institute. Dawn M. Holman, MPH, Zahava Berkowitz, MSc, MSPH, Gery P. Guy Jr, PhD, Mona Saraiya, MD, Marcus Plescia, MD, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Dawn M. Holman, dholman@cdc.gov, 770-488-4262.

Editorial Note

Surveying sun protective behaviors and sunburn over time is a method for measuring the impact of skin cancer prevention activity and tracking progress toward achieving Healthy People 2020 objectives, which include increasing the proportion of persons who participate in behaviors that reduce their exposure to harmful ultraviolet (UV) irradiation and avoid sunburn (8).* The findings in this report suggest an increase in sunscreen use, shade use, and wearing long clothing to the ankles in recent years among persons aged 18–29 years but no corresponding decrease in the proportion reporting sunburn.

The effectiveness of each protective behavior depends on the specific conditions and proper use (10). Similar to the findings of other studies, sunscreen use was one of the most commonly reported protective behaviors, but sunscreen use remained low, with only 37.1% of women and 15.6% of men reporting use always or most of the time (8,10). Under new regulations announced by the Food and Drug Administration, which will take effect by the summer of 2012, all sunscreens will be labeled for the indication of helping prevent sunburn.The SPF value indicates the level of protection a sunscreen provides against sunburn, which primarily is caused by UVB radiation. However, sunscreens that are labeled "broad spectrum" also will have demonstrated equivalent levels of UVA protection. Those labeled "broad spectrum" with an SPF ≥15 therefore will have high levels of both UV and UVB protection and will be labeled for the indication of helping to reduce the risk for skin cancer and premature skin aging when used in conjunction with other protective measures (e.g., limiting time in the sun, especially between the hours of 10 a.m. and 2 p.m., and wearing protective clothing, hats, and sunglasses).

The findings in this report are subject to at least five limitations. First, this study relies on self-reported information that is subject to recall and social desirability bias. Second, proper use of sun protection methods (e.g., adequate application of sunscreen) could not be assessed. Third, because of differences in questions, not all protective behaviors could be assessed for every survey year. Fourth, information was not available to determine the proportion of sunburns attributable to sun exposure versus tanning bed use. Finally, for this analysis, no data were collected on sun sensitivity, the amount of time spent in the sun, or sunburn severity, and no distinction was made between participants who had one sunburn or multiple sunburns, all factors that can be associated with the degree of risk for skin cancer (3,7).

Continued public health efforts are needed to facilitate sun protection, prevent sunburn, and avoid increases in skin cancer cases. Evidence from a recent review by the U.S. Preventive Services Task Force suggests that behavioral counseling in a primary-care setting can increase sun protective behaviors, particularly among persons aged 10–24 years.§ Additionally, environmental and policy changes (e.g., provision of shade and sunscreen in recreational settings) could be promising strategies for creating social and physical environments that routinely promote sun protection for younger adults and persons of all ages.

References

  1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283–7.
  2. Guy GP, Ekwueme DU. Years of potential life lost and indirect costs of melanoma and non-melanoma skin cancer: a systematic review of the literature. Pharmacoeconomics 2011;29:863–74.
  3. Karagas MR, Weinstock MA, Nelson HH. Keratinocyte carcinomas (basal and squamous cell carcinomas of the skin). In: Schottenfeld D, Fraumeni JF, eds. Cancer epidemiology and prevention. 3rd ed. New York, NY: Oxford University Press; 2006:1230–50.
  4. Jemal A, Saraiya M, Patel P, et al. Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992–2006. J Am Acad Dermatol 2011;65(5 Suppl 1):S17–25.
  5. Green A, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol 2011;29:257–63.
  6. Macbeth AE, Grindlay DJ, Williams HC. What's new in skin cancer? An analysis of guidelines and systematic reviews published in 2008–2009. Clin Exp Dermatol 2011;36:453–8.
  7. Dennis LK, VanBeek MJ, Beane Freeman LE, Smith BJ, Dawson DV, Coughlin JA. Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis. Ann Epidemiol 2008;18:614–27.
  8. Buller DB, Cokkinides V, Hall HI, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: review from national surveys and case studies of 3 states. J Am Acad Dermatol 2011;65(5 Suppl 1):S114–23.
  9. Hartman AM, Crafts J, Yaroch A, McNutt S, Summerall T, Willis G. A picture is worth a thousand words: results from cognitive testing of graphic show cards. Alexandria, VA: American Statistical Association; 2005:2868–71.
  10. Linos E, Keiser E, Fu T, et al. Hat, shade, long sleeves, or sunscreen? Rethinking US sun protection messages based on their relative effectiveness. Cancer Causes Control 2011;22:1067–71.


What is already known on this topic?

Previous data have indicated that most U.S. adults aged 18–29 years do not regularly engage in protective behaviors when outdoors in the sun, and approximately half have experienced sunburn in the past year.

What is added by this report?

Although some sun protective behaviors, including shade and sunscreen use and wearing long clothing to the ankles, have increased in recent years among adults aged 18–29 years, the prevalence of sunburn in 2010 remained high (50.1%), especially among whites (65.6%).

What are the implications for public health practice?

Provision of shade and sunscreen in recreational settings and clinical counseling of younger adults are promising strategies for creating environments and social norms that facilitate sun protection and sunburn prevention in this population.


FIGURE 1. Prevalence* of sun protective behaviors among women aged 18–29 years, by survey year — National Health Interview Survey, United States, 2000, 2003, 2005, 2008, and 2010

The figure shows the prevalence of sun protective behaviors among women aged 18-29 years, by survey year in the United States during 2000, 2003, 2005, 2008, and 2010. Among women, using sunscreen (37.1%, CI = 34.7-39.5) and staying in the shade (34.9%, CI = 32.6-37.3) were the most common protective behaviors reported in 2010.

Abbreviation: SPF = sun protection factor.

* Age-adjusted to the 2000 U.S. population using the age groups 18–24 and 25–29 years.

The percentage who reported engaging in each sun protective behavior always or most of the time when outdoors in the sun. Response options included "always," "most of the time," "sometimes," "rarely," or "never."

§ Each year, participants were asked, "What is the SPF number of the sunscreen you use most often?" In 2005, 2008, and 2010, participants who responded to this question with "more than one," "different ones," or "other" also were asked, "Is the SPF usually 1–14 or 15–50?" as a probe to decrease missing data.

Only asked in 2005, 2008, and 2010.

** Data on wide-brimmed hat use in 2000 and 2003 are not shown. Data from 2005, 2008, and 2010 are thought to more accurately estimate wide-brimmed hat use because of the addition of a question about wearing "a baseball cap or sun visor" and the use of pictures of examples of wide-brimmed hats, starting in 2005.

Alternate Text: The figure above shows the prevalence of sun protective behaviors among women aged 18-29 years, by survey year in the United States during 2000, 2003, 2005, 2008, and 2010. Among women, using sunscreen (37.1%, CI = 34.7-39.5) and staying in the shade (34.9%, CI = 32.6-37.3) were the most common protective behaviors reported in 2010.


FIGURE 2. Prevalence* of sun protective behaviors among men aged 18–29 years, by survey year — National Health Interview Survey, United States, 2000, 2003, 2005, 2008, and 2010

The figure shows the prevalence of sun protective behaviors among men aged 18-29 years, by survey year in the United States, during 2000, 2003, 2005, 2008, and 2010. Among men, wearing long clothing to the ankles was the most common protective behavior reported in 2010 (32.9%, CI = 30.5-35.3), followed by staying in the shade (25.6%, CI = 23.4-27.9), and using sunscreen (15.6%, CI = 13.8-17.6).

Abbreviation: SPF = sun protection factor.

* Age-adjusted to the 2000 U.S. population using the age groups 18–24 and 25–29 years.

The percentage who reported engaging in each sun protective behavior always or most of the time when outdoors in the sun. Response options included "always," "most of the time," "sometimes," "rarely," or "never."

§ Only asked in 2005, 2008, and 2010.

Each year, participants were asked, "What is the SPF number of the sunscreen you use most often?" In 2005, 2008, and 2010, participants who responded to this question with "more than one," "different ones," or "other" also were asked, "Is the SPF usually 1–14 or 15–50?" as a probe to decrease missing data.

** Data on wide-brimmed hat use in 2000 and 2003 are not shown. Data from 2005, 2008, and 2010 are thought to more accurately estimate wide-brimmed hat use because of the addition of a question about wearing "a baseball cap or sun visor" and the use of pictures of examples of wide-brimmed hats, starting in 2005.

Alternate Text: The figure above shows the prevalence of sun protective behaviors among men aged 18-29 years, by survey year in the United States, during 2000, 2003, 2005, 2008, and 2010. Among men, wearing long clothing to the ankles was the most common protective behavior reported in 2010 (32.9%, CI = 30.5-35.3), followed by staying in the shade (25.6%, CI = 23.4-27.9), and using sunscreen (15.6%, CI = 13.8-17.6).


TABLE. Prevalence* of at least one sunburn in the past 12 months among adults aged 18–29 years, by sex and race/ethnicity — National Health Interview Survey, United States, 2000, 2005, and 2010

Sex and race/ethnicity

2000 (N = 5,980)

2005 (N = 5,416)

2010 (N = 4,914)

%

(95% CI)

%

(95% CI)

%

(95% CI)

Women

White

65.6

(62.8–68.4)

61.0

(58.4–63.6)§

65.9

(62.5–69.1)

Black

12.8

(9.4–17.1)

12.5

(9.1–16.8)

12.8

(9.7–16.9)

Hispanic

33.0

(28.7–37.7)

28.2

(24.5–32.3)

38.3

(33.7–43.0)

Other race

33.1

(24.2–43.4)

31.4

(20.2–45.3)

31.2

(22.8–40.9)

Total

51.8

(49.6–54.1)

46.9

(44.9–49.0)§

51.3

(48.8–53.7)

Men

White

65.2

(62.3–68.1)

59.0

(55.5–62.4)§

65.3

(61.7–68.7)

Black

6.4

(4.1–9.8)

6.2

(3.5–10.8)

8.7

(5.2–14.2)

Hispanic

30.8

(26.4–35.6)

26.2

(22.6–30.1)

32.4

(28.2–36.9)

Other race

18.1

(12.3–25.8)

19.7

(11.8–31.1)

23.1

(16.1–31.9)

Total

49.9

(47.5–52.4)

44.1

(41.5–46.7)§

49.1

(46.4–51.7)

Total

50.9

(49.3–52.5)

45.5

(43.9–47.2)§

50.1

(48.2–52.0)

Abbreviation: CI = confidence interval.

* Estimates are age-adjusted to the 2000 U.S. population using the age groups 18–24 and 25–29 years.

Persons identified as Hispanic might be of any race. Persons identified as white, black, or other race are all non–Hispanic.

§ Statistically significant difference compared with 2000.


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