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The number of new cases of melanoma skin cancer increased between 1975 and 2009, with a projected number of 76,250 new cases in 2012. More than two million people were diagnosed with basal cell and/or squamous cell (non-melanoma) skin cancer in the United States in 2006. Basal and squamous cell cancers are the two most common types of cancers in the country. Although 40 to 50 percent of Americans who live to age 65 will have non-melanoma at least once, most of these cancers—as well as melanoma, the deadliest form of skin cancer—can be prevented. Studies suggest that reducing unprotected exposure to the sun and avoiding artificial ultraviolet (UV) light from indoor tanning beds, tanning booths, and sun lamps can lower the risk of skin cancer. Avoiding sunburns, intermittent high-intensity sun exposure, indoor UV tanning, and other damage from these sources—especially in children, teens, and young adults—reduces the chances of getting melanoma skin cancer. Although these types of skin cancers do occur in people with darker skin, they are most common in light-skinned people.
Sun-protective behaviors:Percentage of adults aged 18 and older who reported that they usually or always practice at least one of three sun protective behaviors—using sunscreen, wearing protective clothing (long sleeve shirt and/or wide brimmed hat shading the face, ears and neck), 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.
In certain sections of this report, the protective clothing and sunscreen measures were defined according to the HP2020 objectives with data available since 2005, only allowing for short-term trends. HP2020 defines use of protective clothing as wearing a wide-brimmed hat that shades the face, ears, and neck, or long sleeves and long pants or long skirt. Use of long pants and/or long skirts was not tracked until 2005. HP2020 guidelines for sunscreen use refer to sunscreens with sun protective factor (SPF) 15+.
Indoor tanning:The National Health Interview Survey Cancer Control Supplement (NHIS-CCS) data began to track indoor tanning use by adolescents in 2005. The percentage of teens aged 14 to 17 years who have used an indoor tanning device one or more times during the past 12 months is given 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 given for 2010. Although NHIS-CCS also collected this data for adults in 2005 and 2008, the methodology used then likely resulted in overestimates and thus we chose not to look at trends.
Sunburn: Percentage of adults aged 18 and older who reported having been sunburned in the past 12 months.
1992–2010 (sun-protective behaviors)
2005–2010 (teen indoor tanning, HP2020 sun-protective behaviors)
2010 (adult indoor tanning)
From 1992 to 2010, there was a non-significant increase in the percentage of adults reporting use of one or more sun-protective behaviors. Overall, by 2010, 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 16 percentage points from 1992, when the percentage was 53.7. Also, the percentage of those reporting one or more sun-protective behaviors in 2010 still represents nearly a 7 percentage point increase over the 1992 value even after differentiating the use of fully sun-protective hats from the use of baseball caps since 2005.
This long-term non-significant increase trend pattern was the same by sex, age, sex by age, race/ethnicity, poverty status, and education.
The short-term trend, from 2005 to 2010 for the HP2020 defined set of one or more sun-protective behaviors, showed a statistically significant rise.
This short-term statistically significant rising trend was similar by sex, age, sex by age, race/ethnicity, and poverty level except for 18- to 24-year old females and greater than or equal to 200 percent of the federal poverty level groups, which showed a non-significant rise.
Protective clothing:The long-term trend in percentage of people who usually or always wear at least one sun-protective article of clothing (fully sun-protective hat or long-sleeved shirt) has not changed significantly over the period 1992–2010. Women’s practices of these behaviors show an overall fall from 1992 to 2010. However, this fall is only statistically significant for those aged 25 years and older, while women 18 to 24 years old showed no significant change. Men’s practices of these behaviors show no significant change overall or by age group. 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, as shown by a 30 percentage point difference in 2005 between the estimate counting long- sleeve shirts and/or fully sun-protective hats and the estimate counting these articles of clothing plus baseball caps. Non-Hispanic whites and non-Hispanic blacks experienced no significant change in protective clothing use from 1992 to 2010, while use of protective clothing by Hispanics remained stable. Long-term trends by poverty status are similar overall. However the recent period from 2005 to 2010 shows a rise in protective clothing use among those who live at or above 200 percent of the federal poverty level, while percentages of those with lower incomes who wear protective clothing show no significant change. There are no differences in trend by education level.
The short-term trend, from 2005 to 2010 for the HP2020 defined set of one or more protective clothing articles, shows a statistically significant rise. This trend is similar overall by sex but not by sex by age group. Only women ages 25 years and older show a statistically significant rise over this time period. The overall rise is similar for non-Hispanic blacks and Hispanics, but non-Hispanic whites show no significant change. The rise is similar by poverty level and by education.
Shade:The long-term trend in 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, by poverty level, and by education level. The percentage of adults ages 18 to 24 who usually or always seek shade rose from 1992 to 2010. Most recently, between 2008 and 2010, use of shade has risen and this finding is consistent by sex, age, sex by age group, race/ethnicity, poverty level, and education.
Sunscreen:Overall, the long-term trend in percentage of people who usually use sunscreen remained fairly stable from 1992 to 2010. Long term trends are similarly stable or show no significant change by sex, age, race/ethnicity, poverty level, and education. One exception to this pattern is for women ages 25 years and older who show a small but statistically significant rise over this period.
The level of SPF, which is in line with the intent of the HP2020 goal (SPF15+) for use of sun-protective measures, was tracked beginning in 2000. The updated HP2020 objectives also refer to sunscreens with SPF 15+. Short-term trends between 2005 and 2010 show an overall rise for adults’ use of sunscreens with SPF 15+. This rise appears to be mainly between 2005 and 2008, with greater stability between 2008 and 2010. These trends were similar among men and women, among various race/ethnicity groups, by poverty level, and by education level. A non-significant change among those 18 to 24 years of age seems to be driven by a non-significant change for young men 18 to 24 years of age because the other sex by age categories show a similar rising trend.
Indoor tanning: Between 2005 and 2010 indoor tanning use fell among teens 14 to 17 years of age. This decline in use was primarily due to a decline in use among girls between 2005 and 2008, as boys showed no significant change during the entire period. The fall in indoor tanning use between 2005 and 2010 was statistically significant only for non-Hispanic whites, while Hispanics and non-Hispanic blacks showed no significant change.
Sunburn: Overall, the percentage of people who reported being sunburned within the past 12 months remained stable from 2000 to 2005 and rose from 2005 to 2010. These trends varied little overall by sex, age, race/ethnicity, poverty status, or education level. The only trend variations were among 18- to 24-year old women and those with less than a high school education, which showed no significant change between 2005 and 2010.
For this section, we generally present the two most recent estimates. The first is based on the measures we use for long-term trends described earlier in this chapter. The second estimate in parentheses is for the HP2020 defined measure where there are differences in construction.
Sun protective behaviors: In 2010, 60.6 (70.0) percent of adults said they usually or always protected themselves from the sun by practicing at least one of three sun-protective behaviors:
Only 48.3 (59.4) percent of young adults aged 18 to 24 reported usually or always protecting themselves from the sun, whereas 62.3 (71.5) percent of those 25 years of age and older reported usually or always protecting themselves. Among men aged 18 years and older, only 52.0 (66.5) percent reported usually or always protecting themselves from the sun, in contrast to 68.5 (73.4) 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 (70.3 [74.8] percent).
58.8 (68.3) percent of non-Hispanic whites, 63.1 (72.7) percent of non-Hispanic blacks, and 64.9 (74.9) percent of Hispanics usually use some form of sun protection. Among those whose income is less than 200 percent of the poverty level, 59.9 (71.2) percent use some form of sun protection. Among those with higher incomes, 60.4 (69.3) percent use some form of sun protection. The percentage of adults using some form of sun protection varies little with educational level, with 60.5 (74.0) percent of adults with less than high school education, 57.6 (69.1) percent of adults with high school education, and 64.6 (71.9) percent of adults with greater than high school education reporting that they usually or always protect themselves from the sun.
Indoor tanning: In 2010, 5.6 percent of adults 18 years of age and older reported using indoor tanning devices in the past 12 months. Females aged 18 to 24 were most likely to use indoor tanning devices (21.2 percent), followed by females aged 25 and older (7.1 percent). Males were less likely than females to use indoor tanning devices, with 4.3 percent of males aged 18 to 24 and 2.0 percent of males aged 25 and older reporting using an indoor tanning device in the past 12 months. Those using indoor tanning devices were primarily non-Hispanic whites (8.1 percent), followed by Hispanics (1.6 percent), and non-Hispanic blacks (0.3 percent). Although 6.6 percent of those with incomes more than 200 percent of the poverty level used these devices, 3.9 percent of those within 200 percent of the poverty level also used these devices. Only 2.0 percent of adults with less than a high school education used tanning devices, compared to 4.9 percent of those with high school education and 5.0 percent of those with greater than high school education.
In 2010, 4.4 percent of those aged 14 to 17 years used tanning devices during the past 12 months. Girls’ use (7.9 percent) of such devices was over six times more than boys’ use (1.2 percent). Use among non-Hispanic whites was 6.7 percent, while use of these devices was 1.6 percent among Hispanics and 0.7 percent among non-Hispanic blacks. Teen use was highest among non-Hispanic white girls, and use increased with age. Non-Hispanic white girls who were 17 years old showed the highest percentages of indoor tanning, with 21.1 percent use, while 14-year-olds’ use was 5.8 percent.
Sunburn: In 2010, 37.5 percent of adults 18 years of age and older reported being sunburned in the past 12 months. Young adults ages 18 to 24 were more likely to be sunburned (51.9 percent of females and 50.0 percent of males) than adults 25 and older (34.5 percent of females and 36.7 percent of males). Non-Hispanic whites (47.4 percent) were far more likely than Hispanics (24.8 percent) or non-Hispanic blacks (10.9 percent) to be sunburned. Adults with less than high school education were less likely to be sunburned (22.8 percent) than adults with high school education (33.1 percent) or greater than high school education (39.3 percent). Of adults living at or above 200 percent of the federal poverty level, 41.8 percent reported being sunburned in the past year compared to 29.0 percent of adults with incomes less than 200 percent of the poverty level.
Increase to 80.1 percent the proportion of adults who follow protective measures that may reduce the risk of skin cancer (such as avoid the sun between 10 a.m. and 4 p.m., usually or always apply sunscreen with an SPF of 15 or higher, wear protective clothing, or seek shade).
Increase to 11.2 percent the proportion of adolescents in grades 9 through 12 who follow protective measures that may reduce the risk of skin cancer.
Decrease to 13.7 percent the proportion of adults 18 and older who report using artificial sources of UV light for tanning; this target is under modification and likely will be lowered.
Decrease to 14 percent the proportion of adolescents in grades 9 through 12 who report using artificial sources of UV light for tanning. Note: This target is based on self-reported student grade 9–12 data from the 2009 YRBS which is not directly comparable to our household proxy data for 14 to 17 year olds. However, demographic patterns are consistent between the two types of estimates. Only data from 2009 is available at present from YRBS on self-reported.
Healthy People 2020 objectives to reduce the proportion of adolescents and adults who report sunburn are in development.
Younger adults and men of any age are less likely to protect themselves from the sun. Younger adults are more likely to be sunburned than older men or women. Adults with incomes below 200 percent of the poverty level are less likely to use sunscreen. Non-Hispanic whites are far likelier than Hispanics and non-Hispanic blacks to be sunburned. Although non-Hispanic whites are more likely to wear sunscreen, they are less likely to wear protective clothing or seek shade than the other race/ethnic groups examined. Less educated adults are less likely to wear sunscreen. Young adult women and teen girls, especially non-Hispanic whites, are most likely to get too much exposure to artificial light through indoor tanning. Young adult women in the Midwest (e.g., in Minnesota) show particularly high use of indoor tanning and also an increasing incidence of melanoma.
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 for prevention of 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 assume that vitamin D is a solution for good health.
The AICR-WCRF report concluded that its review of cohort studies provided limited evidence suggesting that foods containing vitamin D or vitamin D status are protective against colorectal cancer. In 2008, an International Agency for Research on Cancer (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. Research published in 2010 by the Vitamin D Pooling Project (VDPP), an international collaboration of investigators that includes NCI scientists, found that elevated levels of vitamin D in the blood did not reduce risk of non-Hodgkin lymphoma or cancers of the endometrium, esophagus, stomach, kidney, ovary, or pancreas.
In 2010, the Institute of Medicine (IOM) released new recommendations for the amounts of vitamin D that Americans should consume. The IOM concluded that vitamin D has clear benefits for bone health but that the relationship between vitamin D intake and risk for cancer, heart disease, stroke, or other chronic illness is inconclusive. The IOM called for more research on the effect of vitamin D supplements for lowering disease risk and on the potential side-effects of taking vitamin D supplements. Currently, NCI is sponsoring the Vitamin D and Omega-3 Trial (VITAL), which investigates the effect of taking daily vitamin D supplements on developing cancer, heart disease, and stroke.
Some research suggests that people often apply a 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 randomized clinical trial in Australia, 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. Long-term follow-up of this randomized trial showed that, among adults age 25 to 75 years, regular application of SPF 15 sunscreen resulted in a protective effect for invasive melanoma, which showed a 73 percent decrease after approximately 15 years of follow up.
In 2011, the Food and Drug Administration (FDA) announced new regulations to improve labeling on sunscreen about UVA and UVB, because previous labeling was considered to mislead the public about the protection they are getting from the sun. Prior rules on sunscreen labeling dealt primarily with UVB sun rays, which are the main cause of sunburn, and the sun protection factor (SPF) value indicated only a sunscreen’s UVB protection level. However, UVA rays contribute to skin cancer and early aging. Under the new regulations, sunscreens with the label “broad spectrum” offer proportional levels of protection against both UVB and UVA rays, and “broad spectrum SPF” values indicate a higher level of protection against UVA as well as UVB rays. Under the new rules, only broad spectrum sunscreens with an SPF of 15 or higher can claim to reduce skin cancer risk. Furthermore, sunscreen labeling cannot state that a sunscreen is “waterproof” or “sweatproof,” or that it is a “sunblock,” as these claims may overstate the product’s effectiveness. These new regulations will go into effect for most manufacturers in summer 2012.
Indoor tanning device use before age 35 increases melanoma risk by 75 percent, making childhood, adolescence, and early adulthood particularly vulnerable periods for future development of skin cancer. WHO recommends that access to tanning beds be restricted for those younger than 18 years of age. As of May 2012, 32 states had enacted laws restricting minors’ access to tanning facilities by age or through parental permission. Of these states, seven have enacted bans for those younger than 14 years of age, two have enacted bans on those younger than age 16 or 17 (Texas, younger than age 16.5 years; Wisconsin, younger than age 16), while only two states recently enacted a ban for those younger than 18 years old—California, the first state is now joined by Vermont. The first county to enact a ban for those younger than 18 years old was Howard County, Maryland just a few years ago. Adults as well as teens and children could also be protected by future FDA regulations proposed for indoor tanning equipment/facilities. Passed in 2011, the Affordable Health Care Act includes a 10 percent excise tax on indoor tanning device use.
Pichon et al. 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 five-year period are loosely consistent with the overall increase in localities and states that have enacted laws restricting indoor tanning for young teen 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. It will be important to confirm the recent decline in youth indoor tanning reported by proxy with self reported 2011 YRBS student survey data which will become available later this year. 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.