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Prevalence of sunburn, sun protection, and indoortanning behaviors among Americans: Review from

national surveys and case studies of 3 statesDavid B. Buller, PhD,a Vilma Cokkinides, PhD,b H. Irene Hall, PhD,c Anne M. Hartman, MS, MA,d

Mona Saraiya, MD, MPH,c Eric Miller, PhD, MPH,e Lisa Paddock, MPH,f and Karen Glanz, PhD, MPHg

Golden, Colorado; Atlanta, Georgia; Bethesda, Maryland; Austin, Texas; Trenton, New Jersey; and

Philadelphia, Pennsylvania

CME INSTRUCTIONS

Please note this is one article that is part of a 16-article CME supplement. CME credit

should only be claimed after reading the entire supplement which can be accessed

via the Melanoma Supplement tab under the Collections By Type pulldown

menu onhttp://www.jaad.org.

This journal supplement is a CME activity (enduring material) co-sponsored by the

American Academy of Dermatology and the Centers for Disease Control andPrevention and is made up of four phases:

1. Reading of the CME Information (delineated below)

2. Reading all the articles in this supplement

3. Achievement of a 70% or higher on the online Post Test

4. Completion of the CME Evaluation

CME INFORMATION AND DISCLOSURES

Statement of Need:

Healthcareproviders continueto underreport melanomaeven thoughcancer reporting

requirements mandate such reporting. Additionally, providers may be unaware of

recent trends and descriptive epidemiology regarding melanoma which includes

the fact that nonwhites have a higher mortality rate from melanoma than do whites.

Target Audience:

Dermatologists, dermatopathologists, general physicians, and public health

professionals.

Accreditation

The AmericanAcademy of Dermatology is accreditedby the Accreditation Council for

Continuing MedicalEducationto providecontinuing medicaleducationfor physicians.AMA PRA Credit Designation

The American Academy of Dermatology designates this enduring material for a

maximum of7 AMA PRA Category 1 Credits. Physiciansshould claimonly thecredit

commensurate with the extent of their participation in the activity.

AAD Recognized Credit

This CME activity is recognized by the American Academy of Dermatology for 7 AAD

Recognized Credits and may be used toward the American Academy of

Dermatologys Continuing Medical Education Award.

Disclaimer:

The American Academy of Dermatology is not responsible for statements made by

the author(s). Statement or opinions expressed in this activity reflect the views of the

author(s) and do not reflect the official policy of the American Academy of

Dermatology. The information provided in this CME activity is for continuing

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options of a specific patients medical condition.

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The editors involved with this CME activity and all content validation/peer reviewers

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The authors of this CME activity have reported no relevant financial relationships

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commercial interest(s).

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In accordance with the ACCME Standards for Commercial Support of CME, the

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planning and implementation of this CME activity, to identify and mitigate conflits

of interest for all individuals in a position to control the content of this CME

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Learning Objectives

After completing this learning activity, participants should be able to describe recent

trends in the epidemiologic patterns of melanoma, including ethnic disparities in

melanoma mortality; identify when a private practice dermatologist is required toreport melanoma casesto a cancerregistry; locateand accesscentralcancer reporting

registries (http://apps.nccd.cdc.gov/cancercontacts/npcr/contacts.asp); and recog-

nize and access national and state-based sources on surveillance systems for sun

protection behaviors.

Date of release: November 2011

Expiration date: November 2014

2011 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2011.05.033

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S114.e1
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Background:Exposure to ultraviolet radiation (from solar and nonsolar sources) is a risk factor for skincancer.

Objective:We sought to summarize recent estimates on sunburns, sun-protection behaviors, and indoortanning available from national and selected statewide behavioral surveys.

Methods:Estimates of the prevalence of sunburn, sun-protection behaviors, and indoor tanning by USadults, adolescents, and children collected in national surveys in 1992, 2004 to 2005, and 2007 to 2009 wereidentified and extracted from searches of computerized databases (ie, MEDLINE and PsychINFO),reference lists, and survey World Wide Web sites. Sunburn estimates from 3 state Behavioral Risk FactorsSurveillance Systems were also analyzed.

Results:Latest published estimates (2005) showed that 34.4% of US adults were sunburned in the pastyear. Incidence of sunburns was highest among men, non-Hispanic whites, young adults, and high-income groups in national surveys. About 3 in 10 adults routinely practiced sun-protection behaviors, and

women and older adults took the most precautions. Among adolescents, 69% were sunburned in theprevious summer and less than 40% practiced sun protection. Approximately 60% of parents appliedsunscreen and a quarter used shade to protect children. Indoor tanning was prevalent among youngeradults and females.

Limitations:Limitations include potential recall errors and social desirability in self-report measures, andlack of current data on children.

Conclusion: Many Americans experienced sunburns and a minority engaged in protective behaviors.Females and older adults were most vigilant about sun protection. Substantial proportions of young

women and adolescents recently used indoor tanning. Future efforts should promote protective hats,clothing, and shade; motivate males and younger populations to take precautions; and convince womenand adolescents to reduce indoor tanning. ( J Am Acad Dermatol 2011;65:S114.e1-11.)

Key words:adults; Behavioral Risk Factor Surveillance System; children; Health Information NationalTrends Survey; indoor tanning; National Health Interview Survey; skin cancer risk; sun protection; sunburn;sunscreen; ultraviolet radiation; Youth Risk Behavior Survey.

Exposure to ultraviolet (UV) radiation, bothfrom the sun and indoor tanning devices, is a riskfactor for the development of melanoma andnonmelanoma skin cancers.1,2 Americans are ad-

vised to reduce UV exposure and avoid sunburnsby limiting time in the midday sun, wearing

protective clothing and sunscreen, and seekingshade when outdoors at midday, and by avoidingindoor tanning devices for any purpose other thantherapeutic benefit.1,3

This article is a review of the most recent estimatesof sunburn and indoor tanning, two risk factors for

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From Klein Buendel Inc, Goldena; American Cancer Society,

Atlantab; Centers for Disease Control and Prevention, Atlantac;

National Cancer Institute, Bethesdad; Texas Department of State

Health Servicese; New Jersey State Cancer Registryf; and Univer-

sity of Pennsylvania.g

Publication of this supplement to the JAADwas supported by the

Division of Cancer Prevention and Control, Centers for Disease

Control and Prevention (CDC).

Conflicts of interest: None declared.

The opinions or views expressed in this supplement are those of

the authors and do not necessarily reflect the opinions,

recommendations, or official position of the journal editors,

the Centers for Disease Control and Prevention, or the National

Cancer Institute.

Accepted for publication May 19, 2011.

Reprint requests: David B. Buller, PhD, Klein Buendel Inc, 1667

Cole Blvd, Suite 225, Golden, CO 80439. E-mail: dbuller@

kleinbuendel.com .

0190-9622/$36.00

J AMACADDERMATOLVOLUME65, NUMBER5

Buller et al S114.e2
http://www.elsevier.com/wps/find/privacypolicy.cws_home/privacypolicymailto:[email protected]:[email protected]:[email protected]:[email protected]://www.elsevier.com/wps/find/privacypolicy.cws_home/privacypolicy

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skin cancer, and of sun-protective behaviors, avail-able from national surveys. Sunburn has a lifetimerelative riskfor melanoma of up to 1.6 and is a risk atall ages.4,5 Although non-Hispanic whites are thefocus of most published analyses, this article alsoreviews data on blacks and Hispanics. The review isrestricted to describing the US population.

Sunburn prevalence datafrom the Behavioral RiskFactor Surveillance System(BRFSS) in Colorado, NewJersey, and Texas are pre-sented to complement na-tional BRFSS data. Sunburnprevalence is an early, feasi-ble, and intermediary endpoint of skin cancer pro-grams. State-level analyses

highlighted geographic var-iation in the context of thesestates environments, popu-lations, and skin cancer inci-dence. Data at the state orcommunity level can assiststatewide planning and eval-uation efforts in skin cancerprevention.

METHODSReview of national

surveys on prevalence ofsunburn, sun protection,and indoor tanning

A review of published analyses of the prevalenceof sunburn, sun-protection behaviors, and indoortanning from national surveys of the US populationwas conducted. Published analyses were identified bysearching computerized databases (eg, MEDLINE andPsychINFO) using terms such as sun, ultravioletradiation, sunscreen, sunburn, sun safety, andsun protection along with population descriptorssuch as adults, adolescents, children, whites,

Hispanics, and African Americans. Reference listsof identified publications were hand searched.Publications were reviewed by the authors for rele-vance and retained when they reported nationalestimates of the prevalence of sunburn, sun-protection behaviors, and indoor tanning by adults,adolescents and children, and individual racial/ethnicsubgroups. World Wide Web sites were consulted forthe latest overall prevalence estimates from the na-tional surveys identified (Table I).

Estimated prevalence of sunburn, sun-protectionbehaviors, and indoor tanning were located from

several large national cross-sectional surveys. For

adults, prevalence estimates were obtainedfrom: theBRFSS (1999, 2000, 2003, and 2004),6-8 NationalHealth Interview Survey (NHIS) (1992, 2000, 2003,2005, and 2008),9-11 and Health InformationNational Trends Survey (HINTS) (2005 and 2007)12

(Table I), although all available estimates have notbeen published from all years. Original analyses

were conducted using datafrom the 2008 NHIS CancerControl Supplement and the2009 to 2010 Cancer TrendsProgress Report. Prevalenceof sun-protection behaviorsby adolescents was measuredby the Centers for DiseaseControl and Prevention(CDC) National Youth RiskBehavior Survey (YRBS)

(1999, 2001, 2003, 2005,2007, and 2009 [including tan-ning bed use in 2009])13-15

and two surveys (1998 and2004) by the AmericanCancer Society (ACS).16,17

The ACS surveys also as-sessed sunburn. A third sur-vey conducted by the CDC in1998 provided the most re-cent interviews with parents/caregivers on the steps taken

to protect their children fromthe sun.18,19 In 2005 and

2008, the NHIS included questions on indoor tanningby adolescents aged 14 to 17 years using a knowl-edgeable adult proxy.

State case studies: Analysis of sunburnprevalence in Colorado, New Jersey, andTexas

Statewide prevalence of sunburn was estimatedfrom the BRFSS collected in Colorado, New Jersey,and Texas in 1999, 2003, and 2004. The states were

selected because their estimates were readily avail-able to the authors and they have diversity inenvironments, populations, and skin cancer inci-dence. New Jersey has sunshine only 2600 hoursannually, whereas Colorado and Texas average 3100annual sunshine hours. New Jersey and Colorado areat more northern latitudes than Texas. Colorado hasthe highest average statewide elevation; New Jerseyand Texas are near sea level. The states vary inproportion of high-risk white and Hispanic popula-tions (Coloradoe73% white, 18% Hispanic; NewJerseye59% white, 17% Hispanic; Texase44% white,

40% Hispanic). New Jersey and Colorado rank in the

CAPSULE SUMMARY

d Increasing sun safety and reducing

indoor tanning exposure are

recommended by national health

authorities.

d Many Americans experience sunburns

and only a minority take precautions.

d Indoor tanning is most frequent among

non-Hispanic whites, adolescent girls,

and young women.

d Sun-safety promotions should be

targeted to males and younger

populations; aim to increase use of hats,

protective clothing, and shade; and

promote implementation of

(enforceable) minors access-restriction

policies to indoor tanning

establishments combined with effective

indoor tanning risk-reducing behavioral

programs.

J AMACADDERMATOLNOVEMBER2011

S114.e3 Buller et al

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top third among states for age-adjusted melanomaincidence rates (20.99 and 20.82/100,000 respec-tively) andTexas ranks in the bottom third (13.85/100,000).20 New Jersey and Colorado had statewidegoals to reduce skin cancer. New Jersey had state-

wide primary and secondary prevention programs,whereas Texas and Colorado had sun-protectioninterventions in specific locations.

Original analyses were performed to obtainweighted statewide prevalence of sunburn fromthe Colorado, New Jersey, and Texas BRFSS in1999, 2003, and 2004 by race/ethnicity, sex, agegroup, and education, calculated using inter-censalestimates. To allow comparison among years, strat-ified BRFSS data were age-adjusted to the 2000 USstandard population using 4 age groups: 18 to 29, 30to 44, 45 to 64, and older than or equal to 65

yearse

using SUDAAN (RTI International, ResearchTriangle Park, NC). Differences in prevalence wereconsidered statistically significant if confidence in-tervals did not overlap.

RESULTSSunburn and sun protection by adults

Sunburn: Estimates from national sur-veys. One in 3 USadults reported being sunburnedin the 2004 BRFSS7 and 2005 NHIS (Table II). TheBRFSS prevalence represented an increase from 1999in 20 states,7 but the NHIS prevalence was slightly

lower than in 2000.10

BRFSS sunburn prevalence washighest in Midwestern states in 2003.6 One fifth(20.7%) of white adults reported 4 or more sunburnsover the past 12 months in the BRFSS.7

Sunburn prevalence varied by demographic sub-groups. In the BRFSS, more men (35.8% in 1999,37.0% in 2003, 37.0% in 2004) reported being sun-burned than women (28.0%, 30.2%, 30.3%, respec-tively). The NHIS 2000 also found a higherprevalence of sunburn among men (37.7%) thanwomen (34.9%). The 2005 NHIS found similar gen-der differences in sunburn prevalence (35.8% vs

33.1%). Prevalence of sunburns increased from 1999

to 2003 in the BRFSS among non-Hispanic white menand women.

The 2000 NHIS showed the highest sunburnprevalence among non-Hispanic whites andAmerican Indians/Alaskan Natives. Consistent withthis, the 2004 BRFSS found that non-Hispanic whitesand American Indians/Alaskan Natives had the high-est prevalence of 4 or more sunburns.7 Althoughonly comparing 3 groups, the 2005 NHIS showedthat non-Hispanic whites (43.1%) had higher sun-burn prevalence than Hispanics (20.3%) and non-Hispanic blacks (8.0%).

Analyses of the 1999 BRFSS showed that sunburnprevalence was highest in the youngest adults (aged18-29 years, 57.5%) and lowest in the oldest adults(aged $ 65 years, 7.0%)8 and a similar age gradientemerged in the 2003 BRFSS. The 2000 and 2005 NHISdata confirmed a greater prevalence of sunburn

among younger than older adults10,21 (45.6% ofadults aged 18-29 years, 43.6% of adults aged 30-39years, 40.0% of adults aged 40-49 years, 26.6% ofadults aged 50-64years, and 11.2% of adults aged$ 65 years in 200521).

Sunburn was most common among higher socio-economic groups. In the 2003 BRFSS, 47.7% ofrespondents earning $50,000 or more were sun-burned (only 28.3% of those earning \$20,000).Sunburn prevalence was highest among collegegraduates (43.8%; 25.2% of respondents not gradu-ating from high school) in the 2003 BRFSS. The 2003

BRFSS reported differences in sunburn prevalenceby employment status (63.1% of students; 33.0% ofunemployed adults).6

Sunburn: Estimates from Colorado, New Jer-sey, and Texas BRFSS. In Colorado, New Jersey,and Texas, the prevalence of sunburn when combin-ing 1999, 2003, and 2004 ranged from 31.8% for Texasto 43.7% for Colorado (Table III). Demographicpatterns for each state reflected nationwide patterns:sunburn prevalence was higher in males than femalesand among non-Hispanic whites than all othergroups. It also was higher in younger than older

age groups. The prevalence of sunburn was statisti-cally significantly higher for every demographic cat-egory in Colorado than New Jersey and Texas, exceptfor age 65 years or older and non-Hispanic blacks.

Sun protectionData on sun-protection behaviors by adults were

available from the NHIS and HINTS(Table II). In the1992 NHIS9 and the 2007 HINTS,22 approximately 3in 10 adults routinely (most of the time/often oralways) practiced various sun-safe behaviors (TableI). In 2007 HINTS, routine use of long-sleeved shirts

was higher (63.3%), sunscreen (29.2%) and hats

Abbreviations used:

ACS: American Cancer SocietyBRFSS: Behavioral Risk Factor Surveillance

SystemCDC: Centers for Disease Control and

PreventionHINTS: Health Information National Trends

SurveyNHIS: National Health Interview SurveySPF: sun-protection factorUV: ultraviolet

YRBS: Youth Risk Behavior Survey



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Table I. Methods and measures of sunburn, sun protection, and indoor tanning in National Behavioral Surveys of adults a

BRFSS NHIS HINTS YRBS

Methodology

Scope National and state National National National

Period Monthly Periodic Biennial Biennial

Interview

method

RDD/CATI Face-to-face computer-

assisted personal

interviews

RDD/CATI Self-administered pa

questionnaire

Sample [350,000 Adults aged$ 18 y

Approximately 20,000-

40,000 adults aged

$18 y

Approximately 7000 adults

aged $18 y

Approximately 12,00

16,000 high schoo

students in grade

9-12

World Wide Web

site

cdc.gov/BRFSS cdc.gov/nchs/nhis.htm and

appliedresearch.cancer.

gove/surveys/nhis

hints.cancer.gov cdc.gov/yrbs

Measures*

Sunburn Any sunburn and No. of

sunburns in past 12 mo,

even time when small

part of skin was red

for[12 h

Frequency of sunburn

during past 12 mo,

even when small part

of skin turns red or

hurts for $12 h andincludes burns from

sunlamps and other

tanning devices

Not asked

Sun-protective

behaviors

How often use sunscreen

on summer sunny day

(SPF), stay in shade, wear

hat, and long sleevesy

How often stay in shade,

wear fully sun-protective

hat (that shades face,

ears,andneck, eg, hat

with wide brim all

around), wear long-

sleeved shirt, and use

sunscreen (in 2005 later

added:) wear long pants

(or other clothes thatreach ankles) and

baseball caps/sun visors

(separately ahead of

asking fully sun-protective

hats) when outside for[1 h on warm and

sunny day

How often wear sunscreen,

stay in shade/under

umbrella, wear hat, and

wear shirts with sleeves

when outside for[1 h on

warm, sunny day

How often wear

sunscreen with SP

$15 when outsid

[1 h on sunny d

routine sunscreen

how often stayed

shade, wore long

pants, wore long-

shirt, and wore ha

shaded face, earsneck when outsid[1 h on sunny d

(2007 only)

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(32.6%) was unchanged, and shade (27.3%) waslower22 than in 2005 HINTS (16.0%, 27.6%, 34.6%,43.1%, respectively).

Gender and location differences were observedin sun protection. Women were more likely thanmen to report very likely when asked aboutstaying in the shade (24.8% of men; 37.2% ofwomen) and using sunscreen (21.7% of men;41.0% of women) in the 1992 NHIS. By 2005 and2008, a substantial percentage of adults still infre-quently practiced sun protection. Rural residentsused sunscreen more than urban residents in the2005 HINTS but this difference disappeared whenadjusting for demographics and other covariates.23

Rural HINTS respondents were more likely to useshade and wear a hat and long sleeves than wereurban residents.

The percentage of NHIS respondents reporting

one or more of the 3 sun-protective behaviors mostof the time or always increased from 54% in 1992to 58% in 2008.11 The questions about wearinghats for sun protection changed in 2005. The 2008estimate reported here (Table II) uses the morerestrictive fully sun-protective hat definition thatwas aided by graphics and excluded baseball capsand sun visors. Comparing 2005 and 2008 where themeasure of hat use was comparable, a slight in-crease in the use of one or more sun-protectivebehaviors (56%-58%) and a slight increase in use ofsun-protective clothing specifically (18%-21%) were

observed. The percentage of people who usuallyseek shade has shown little change overall (32% in1992 and 2008). Sunscreen use has increased from29% in 1992 to 32% in 2008 (27%-30% for use ofsunscreen with a sun-protection factor [SPF] $ 15).By contrast, the proportion of US adults who prac-ticed all 3 sun-protection behaviors was small24

(10% in 19929).Sun-protection behaviors were associated with

several demographic and attitudinal factors alongwith a history of sunburn and skin cancer. In the 1992NHIS, older adults, females, never married adults,

and adults with a history of skin cancer or concernedabout getting cancer were most likely to reportpracticing at least one sun-protection behavior.Similar differences were seen in the 2005 NHIS andfor demographic factors examined in the 2008NHIS.11,21 High skin sun sensitivity predicted greateruse of all sun-protection behaviors and a history ofsunburns was positively related to wearing protec-tive clothing and using shade. Similarly, adults whoperceived greater risk of getting skin cancer weremore likely to use sunscreen and seek shade.9Adultswith incomes below 200% ofthe poverty level were

less likely to use sunscreen.

11Tanningbeduse

Notasked

Past12-mofrequency

ofusingtanning

devicesesunlamp,sun

bedortanningboo

th;

parents/knowledgeable

adultsreportofuseby

childrenaged14-17

y

Timesusedtanningbedor

boothinpast12mo;

timesusedsunless

tanningcreamsorsprays

inpast12mo

Timesusedindoor

tanningdevicesuchas

sunlamp,sunbed,or

tanningbooth(not

spray-ontan)inpast

12mo

Pastyearu

seofindoor

tanning

sunlampsor

booth

ACS,

AmericanCancerSociety;BRFSS,

BehavioralRiskFactorSurveillanceSystem;CATI,computer-assistedtelephoneinterview;HINTS,

HealthInformationNationalTrendsSu

rvey;NHIS,

National

HealthInterview

Survey;RDD,random-digit

dialed;SPF,sun-protectionfactor;YRBS,Yo

uthRiskBehaviorSurvey.

*Wordingofmeasuresprovidedfrom

most

recentassessmentineachsurvey.

ySun-protectionbehaviorswereassessedonlyinstate-specificmodules;nonationalestimatesareavailable.



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Indoor tanning and sunless tanning productuse by adults

Indoortanning was assessed in the 200514,21 and2008 NHIS14 and the 2005 and 2007 HINTS.22 In the2008 NHIS, 15.2% of adults reported using indoor

tanning in the past 12 months, whereas 8.5% of adultswere estimated to have done so according to the 2007HINTS.22 Indoor tanning was most common by youn-ger adults (eg, 2005 NHIS: 20.2% aged 18-29 years,16.7% aged 30-39 years, 13.6% aged 40-49 years, 9.9%aged 50-64 years, and 7.6% aged $65 years).21

Differences by sex and race-ethnicity were seen inthe 2008NHIS,11 but not by rural residence in 2005HINTS.23 More females (18.3%) than males (12.0%)used indoor tanning devices. Non-Hispanic whitesused them the most (17.8%), followed by Hispanics(11.0%) and then non-Hispanic blacks (9.0%). Finally,

inthe2005HINTS, 11% of adults reportedusing sunlesstanning products in the past year (25% used them[10times), a non-UV alternative to indoor tanning.24

Sunburn and sun protection by adolescentsSunburn. In the 2004 ACS survey, nearly 7 in 10

of adolescents reported a sunburn during the sum-mer (Table II). Sunburn prevalence was unchangedfrom 1998 (69%).17

Sun protectionSunscreen use was reported in the YRBS and ACS

survey. In 2009, just under 1 in 10 high school

studentsroutinely used sunscreen with SPF of 15 orhigher25 (Table II). Prevalence of routine sunscreenuse decreased over thepast,14,26 from 13.3% to 9.3%during 1999 to 2009.25 By contrast, during 1998 and2004, the trend in sunscreen use in the ACS survey

showed a modest increase from 31.4% to 39.4%(Table II).17 In the 2004 ACS sample, 32.1% ofadolescents used sunglasses, 22.8% wore protectiveclothing (ie, long pants or long-sleeved shirts), and21.7% sought shade for sun protection always oroften. However, very few wore wide-brimmed hats(4.9%).

Prevalence of sun-protection behaviors varied inthe 2009 YRBS by sex, race/ethnicity, and grade inschool. Routine sunscreen use was higher in fe-males (12.4%) than males (6.5%) in general andacross non-Hispanic whites, Hispanics, and blacks

and across all high school grades (grades 9-12).25

Itwas highest among non-Hispanic whites (10.6%),followed by Hispanics (7.5%) and blacks (4.6%).In 2003, routine sunscreen use was highest inthe Northeast (19.6%) and lowest in the South(10.6%).14 Routine sunscreen use in 2003 washigher in females (18.1%) than males (8.6%) andhigher among non-Hispanic whites (16.5%) thanblacks (4.8%) and Hispanics (10.8%).14 Routinepractice of other sun-safety behaviors in the 2007YRBS was higher for males (19.4%) than females(15.4%) (across non-Hispanic whites and Hispanics

and in 9th, 11th, and 12th grades but not 10th

Table II.Most recent estimated prevalence (percent of population) of sunburn, sun-protection behaviors, andindoor tanning in national surveys of adults and adolescents in United States

Adults Adolescents

BRFSS

2004

NHIS

2008

HINTS

2007

YRBS

2009

ACS Sun Survey

2004

Sunburn 33.7% 34.4%* 68.7%Sun protection:

Sunscreen with SPF $15 30.4%y 29.2%z,x 9.3%y 39.4%z,x

Long-sleeved shirt 63.3%z

Protective clothing 20.9%y 22.8%z

Wideebrim hat 14.4%y 32.6%z,k 4.9%z

Stay in shade 31.5%y 27.3%z 21.7%z

Sun-protection behaviors except

sunscreen

17.4%y,{

Indoor tanning bed/lamp use 15.2% 9.0% 15.6% 11.0%

Confidence intervals were not included because they were not consistently available. See Table I for description of measures for each of

these behaviors.

ACS, American Cancer Society; BRFSS, Behavioral Risk Factor Surveillance System; HINTS, Health Information National Trends Survey; NHIS,

National Health Interview Survey; SPF, sun-protection factor; YRBS, Youth Risk Behavior Survey.*Estimate from 2005.yPercent responding most of the time or always.zPercent responding often or always.xEstimate of sunscreen without SPF specified.kEstimate of hat without brim specified.{Estimate from 2007.



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grade) and higher among blacks (21.1%) andHispanics (20.9%) than among non-Hispanicwhites (14.9%).26 Patterns of sun-protection behav-ior in the ACS surveys varied by age (highest amongyoungest adolescents), sex (sunscreen use mostprevalent among girls; clothing use most prevalentamong boys), sun sensitivity (highest among thosewith greater sun sensitivity), and race (highest in

those who are white).

17

Indoor tanning by adolescentsIn the 2009 YRBS, 15.6% of high schoolstudents

used indoor tanning devices (Table II),25 a slightincrease from 11% in the 2004 ACS Sun Survey16 and6% in 2008 NHIS (among 14-17 year olds).11 Indoortanning device use in the 2009 YRBS differed bygrade, sex, and race. It was most prevalent amongfemales and non-Hispanic whites (especially non-

Hispanic white femalese

37.4%), and students in

Table III. Age-adjusted prevalence of sunburn (percent of statewide adult population) in 1999, 2003, and 2004Behavioral Risk Factor Surveillance System for Colorado, New Jersey, and Texas

Category Subgroup Year

New Jersey Texas Colorado United States

% (95% CI) % (95% CI) % (95% CI) % (95% CI)

Overall All 3 years 29.8 (29.1-30.5) 31.8 (31.0-32.7) 43.7 (42.5-44.9) 32.9 (32.1-33.7)

Sex Male 1999 30.5 (27.5-33.6) 34.9 (32.5-37.3) 49.9 (46.0-53.7) 35.8 (35.2-36.3)2003 32.7 (31.0-34.3) 35.9 (33.7-38.1) 50.2 (47.5-52.9) 37.1 (36.5-37.6)

2004 33.1 (31.5-34.8) 35.1 (33.0-37.4) 46.5 (43.8-49.3) 37.0 (36.5-37.6)

Female 1999 23.5 (21.1-26.1) 25.5 (23.6-27.4) 38.7 (35.4-41.9) 28.0 (27.5-28.4)

2003 27.9 (26.6-29.2) 25.8 (24.4-27.4) 39.0 (36.8-41.3) 30.3 (29.9-30.7)

2004 27.2 (25.9-28.6) 27.9 (26.3-29.6) 38.2 (36.0-40.4) 30.3 (29.9-30.8)

Age

group, y

18-29 1999 44.2 (38.5-50.0) 44.5 (40.3-48.7) 65.7 (60.0-71.4) 47.2 (46.2-48.2)

2003 43.4 (40.2-46.8) 44.0 (40.4-47.6) 58.6 (54.0-63.2) 46.9 (45.9-47.8)

2004 39.3 (36.0-42.8) 43.1 (39.6-46.7) 52.9 (48.3-57.5) 46.3 (45.3-47.3)

30-44 1999 33.1 (29.6-36.7) 39.4 (36.3-42.6) 55.4 (51.3-59.6) 41.9 (41.2-42.7)

2003 36.9 (35.0-38.8) 36.7 (34.3-39.3) 54.3 (51.2-57.4) 42.6 (41.9-43.3)

2004 37.3 (35.5-39.1) 39.7 (36.9-42.6) 52.2 (49.1-55.3) 42.7 (42.0-43.3)

45-64 1999 19.8 (16.9-23.1) 23.9 (21.4-26.6) 35.5 (31.1-39.8) 24.7 (24.0-25.3)

2003 25.7 (24.1-27.2) 26.6 (24.4-28.8) 39.7 (37.0-42.4) 28.3 (27.7-28.8)2004 27.7 (26.2-29.3) 26.2 (24.0-28.4) 38.1 (35.4-40.8) 29.1 (28.6-29.7)

$ 65 1999 5.7 (3.8-8.5) 6.0 (4.3-8.2) 5.8 (3.3-8.4) 6.7 (6.2-7.2)

2003 9.4 (8.1-10.8) 8.7 (6.9-10.8) 11.0 (8.3-13.7) 9.2 (8.8-9.7)

2004 9.2 (8.1-10.5) 8.7 (6.9-11.0) 10.7 (8.3-13.1) 8.4 (8.0-8.8)

Race/

ethnicity

White-NH 1999 36.5 (34.1-38.9) 42.7 (40.9-44.5) 48.4 (45.6-51.2) 39.6 (39.1-40.0)

2003 41.2 (39.9-42.5) 42.8 (41.0-44.5) 49.1 (47.2-51.0) 42.4 (42.1-42.8)

2004 42.3 (41.1-43.6) 44.8 (43.0-46.7) 48.9 (46.9-50.8) 43.2 (42.8-43.6)

Black-NH 1999 4.2 (2.1-8.0) 7.3 (4.8-44.5) N/A N/A 5.2 (4.6-5.8)

2003 4.8 (3.5-6.4) 5.3 (3.5-8.0) 3.7 (0.0-8.2) 5.2 (4.6-5.8)

2004 6.5 (4.9-8.5) 7.7 (5.5-10.8) 4.0 (0.7-7.3) 5.8 (5.2-6.4)

Hispanic 1999 9.6 (6.3-14.4) 18.0 (15.7-20.6) 32.8 (26.2-39.5) 17.9 (16.8-20.3)

2003 16.5 (13.7-19.7) 19.0 (16.9-21.4) 30.0 (25.3-34.8) 19.6 (18.5-20.8)

2004 13.8 (11.5-16.4) 20.2 (17.7-22.9) 24.3 (19.9-28.7) 17.6 (16.7-18.6)

Education No high

school

diploma

1999 7.7 (4.5-12.9) 15.3 (12.5-18.6) 29.4 21.7-37.0 19.8 (18.7-20.9)

2003 17.9 (14.6-21.8) 19.8 (16.9-23.1) 34.3 27.4-41.2 21.1 (20.1-22.1)

2004 16.8 (13.8-20.4) 19.7 (16.8-23.1) 23.0 16.8-29.2 19.6 (18.6-20.6)

High school

graduate

1999 24.9 (21.6-28.6) 27.3 (24.6-30.2) 39.0 34.2-43.8 30.1 (29.5-30.8)

2003 28.0 (25.9-30.1) 26.7 (24.3-29.2) 40.3 36.7-43.8 31.1 (30.5-31.8)

2004 26.6 (24.7-28.6) 28.1 (25.6-30.7) 37.4 34.0-40.8 30.6 (30.0-31.2)

Some

college

1999 34.0 (30.1-38.1) 34.3 (31.5-37.2) 48.1 43.5-52.7 33.7 (33.0-34.4)

2003 29.9 (27.9-32.0) 34.0 (31.4-36.7) 45.7 42.2-49.1 35.4 (34.8-36.1)

2004 30.8 (28.8-32.9) 34.0 (31.4-36.7) 41.4 38.0-44.8 35.3 (34.6-35.9)

$College 1999 29.2 (25.7-33.0) 39.1 (36.3-42.0) 49.7 45.2-54.2 37.1 (36.3-37.8)

2003 34.7 (32.8-36.6) 39.1 (36.4-41.9) 49.2 46.5-51.9 39.0 (38.4-39.6)

2004 36.2 (34.3-38.2) 39.3 (36.6-42.0) 51.9 49.2-54.5 40.4 (39.8-41.1)

CI, Confidence interval; N/A, not available; NH, non-Hispanic.



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grade 12. Older (16-18 years) adolescent females andthose with medium sun sensitivity (skin tans easilyand does not burn) also used indoor tanning devicesmost in the ACS Sun Survey.16 More girls (10.2%)used such devices than boys in the 2008 NHIS.11

Sunburn and sun protection of childrenNational surveys of parents and caregivers were

conducted in 1997 and 1998 to determine the prev-alence of sun protection for children. For childrenaged 12 years or younger, parents and caregiversreported the use of one or more measures of sunprotection for three quarters of the children.18,19

Sunscreen (61.8%)and shade (26.5%) were reportedmost frequently.19 Fair skin type, younger age of thechild, and parent being married were associated withhigher reported use of sun-protection measures forchildren.19 The majority of sunscreen users applied

an SPF of 15 or more, but did not apply sunscreen 30minutes before going outside to give it time to beabsorbed by the skin and become effective. Amongchildren who wore hats, the majority wore baseballcaps, which do not protect the entire face, ears, andneck from sun exposure.

Sunburn and sun protection among racialminority groups

Few analyses of data from national behavioralsurveys have been reported examining the sunburnand sun protection of racial groups even though skin

cancer is predominately a disease of light-skinnedindividuals in the United States. Sunburn is lessfrequent among racial groups other than non-Hispanic whites: the 2004 BRFSS found that non-Hispanic blacks (5.8% of men and women), Hispanicblacks (12.4% of men; 9.5% of women), Asians/Pacific Islanders (16.2% of men; 16.1% of women),and American Indians/Alaskan Natives (30.4% ofmen; 21.5% of women) had a much lower preva-lence of sunburn than non-Hispanic whites (46.9% ofmen; 39.6% of women).7

The sun protection by Hispanics was explored in

the 2005 HINTS.27

Here, 42.9% reported alwayswearing long pants, 13.3% wearing a long-sleevedshirt, 22.1% wearing a hat, 25.8% seeking shade, and15.3% using sunscreen. Sun protection was associ-ated with sex, age, region, and education. Morewomen sought shade and used sunscreen whereasmore men wore protective clothing. Older as op-posed to younger Hispanics reported more use ofprotective clothing. Protective clothing and sun-screen use was more prevalent in the South andWest than in other regions. Sunscreen use was moreprevalent among Hispanics with more education but

this group was less likely to seek shade or wear

protective clothing, a trend seen among more accul-turated Hispanics (association of sunscreen use withethnicity disappeared in analyses adjusted for cova-riates). Acculturation increased the prevalence ofsunscreen use among younger Hispanics but de-creased use of long pants by more affluent Hispanics.

Responses from blacks in the sample from the1992 NHIS28 showed that 28.2% were very likely towear sun-protective clothing, 44.8% to stay in theshade, and 9.1% to use sunscreen. Sun protectionwas highest among those whose skin was most sunsensitive (based on sun sensitivity, sunburn ten-dency after 1-hour sun exposure, sunburn and tan-ning after repeated sun exposure) and who wereolder. Sunscreen use was highest among blacks withhigher incomes and more education.

DISCUSSIONMany Americans get sunburned and there has

been little improvement in sun-safety behavior overtime. Although adult sunburn prevalence may varyby region, men, non-Hispanic whites, affluent adults,and younger adults appeared to be the highestrisk groups regardless of location, differences alsowitnessed in the state-level analyses. However,Colorado residents reported the highest sunburnprevalence and sunburn prevalence was particularlyelevated among its Hispanic residents. Previouslypublished analyses have not explored demographicor location differences in sunburn rates among

adolescents and children.Many Americans did not protect themselves from

the sun when outdoors. Many adults are trying toprotect themselves but are not doing so comprehen-sively (ie, very few are using all recommendedbehaviors). Men used fewer protective measuresthan females. Sun protection is relatively low amongolder adolescents and young adults compared withyounger adolescents and older adults (but youngeradolescents may not be as protected as the youngestchildren). Experience with UV-induced skin damage(ie, frequent sunburns, highly sun-sensitive skin that

always burns and never tans, or at the extreme, skincancer) may cause older Americans to be morecautious. Sunscreen appears to be the most commonprotection behavior, although boys use it less thangirls during adolescence.

Exposure to non-solar UV is less frequentlyreported than exposure to solar UV, but still about1 in 8 Americans tans indoors. Certain subpopula-tionsewhites and adolescent girls and youngwomen in particularetan indoors more than othergroups.

Conclusion from these data about the success or

failure of efforts to improve sun safety in the United



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States must recognize that there has been very littlenational investment in promoting primary preven-tion of skin cancer.29 Sun-safety interventions havebeen infrequent, notsustained, and not coordinatedin the United States.30 Thus, national skin cancerprevention efforts have not really failed; there justhave not been enough. A national investment inprimary prevention is needed. There may be oppor-tunity to reduce indoor tanning nationally throughregulatory efforts such as the 10% tax on tanning beduse in the federal health reform law and the FederalDrug Administration consideration of age limits ontanning bed use, reclassification of tanning beds asa class II medical device requiring more controlsfor age and skin type, and patient disclosure orbrochure.31

Measurement of sunburn and sun protection

Sunburn and sun-protection behaviors were mea-sured by self-reports in the national and statesurveys, the only feasible type of measure for largepopulation surveys. The measures varied slightly inwording and recall period (Table I) and were notasked every year. Self-report measures are subject torecall errors and/or social desirability biases.Participants were asked to recall recent sunburns,often defined in these surveys (Table I) as even asmall part of your skin turns red or hurts for 12 hoursor more, and other times defined in interventionstudies as skin reddening lasting at least a day or

longer.32 These types of questions are considered tobe reasonably good but can be subject to recall bias.The most common self- or verbal-report measures ofsun protection asked about habitual or typical be-haviors,32,33 which may not capture details such astype of hat, and sunscreen SPF, and rarely capturethoroughness of sunscreen application, reapplica-tion of sunscreen, UV protection factor of clothing,and type of shade.

Verbal self-reports of sun safety (and indoortanning use) will no doubt continue to be used inlarge national surveys, because of ease of adminis-

tration and relatively low cost.33

However, advancesto improve the quality of these data are occurring bytesting the criterion validity of measures of sun-screen use, cover-up behavior, sun exposure,33 andindoor tanning34 and whether subgroups are proneto systematic underreporting or overreporting.People of different age and occupational groupscan provide relatively valid self-reports comparedwith objective measures.35,36 In the NHIS, a ques-tion was added about baseball cap use and showeda card with typical pictures of fully sun-protectivehats to improve estimates.37 Core items to assess

sunburn, sun-protection behaviors, and nonsolar

tanning were recently publishedwith demonstratedclarity and wide applicability.32,34 The future use ofthese items is recommended when feasible toincrease the comparability across surveys, years,and populations.

Concluding remarksThe national surveys, along with the case studies

from 3 states, report convergent findings, althoughthe data on children are very limited. Females andolder adults appear to be most adherent to sun-protection recommendations. Men and youngeradults have larger need for protection from solarUV; however, whites and adolescent and youngwomen need to be protected from indoor tanning,given the higher cancer risks from these sources.38

Sun-safety promotions should be targeted to men

and young populations; aim to increase use of hats,protective clothing, and shade; and promote imple-mentation of (enforceable) minors access-restrictionpolicies to indoor tanning establishments combinedwith effective indoor tanning risk-reducing behav-ioral programs directed primarily to women. Regularnationwide surveillance of sunburn and sun-protection behaviors and regional analyses at thestate and community level may enable further actionby aiding program planning and evaluation andmeasuring the impact of federal and state skin cancerprevention policies or monitoring the shifting public

information on sun safety (eg, prevention campaignsor news coverage such as on the effectiveness ofsunscreens).

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