PracticalDermatology

Skin cancer is the most common cancer in the US, with the number of melanoma and non-melanoma skin cancers continuing to rise each year.¹ It is well known that exposure to ultraviolet radiation and a history of sunburns are important risk factors for basal cell carcinoma (BCC), squamous cell carcinoma(SCC), and melanoma. Regular and complete sunscreen use has been shown to decrease the lifetime incidence of skin cancer.² Therefore, it is important to educate the general population on the importance of sun safety. However, despite this information being available to the public, sunburns are still common. According to the federal Centers for Disease Control and Prevention (CDC), 37.5 percent of US adults reported being sunburned at least once in 2009—with people aged 18-29 having the highest rate at 50 percent, and people aged 66 or older having the lowest rate at 13 percent. It is a Healthy People 2020 goal to reduce the percent of US adults sunburned per year to 33.8 percent.³

Some studies have identified characteristics of people who are more frequently sunburned. Thirty three percent of respondents to a survey of 53,130 people aged 18 or older in six provinces in Canada from 2005-2014 reported that they had experienced a sunburn. Sunburns were most common among men and in younger age groups.⁴ These demographics are in line with individuals who often partake is winter sports, such as skiing. According to a snow sports participation study by Crescent Ski Council, 59.9 percent of skiers are men, with 60.9 percent under the age of 34.⁵ Due to increased UV exposure from reflection off snow, extended hours of UV exposure, and simply being in a demographic at higher risk for sunburns, winter sports participants are an important target group for sun safety education.

Some ski schools have begun to implement sun safety programs into their curriculum. In 26 ski areas in North America, Go Sun Smart (GSS) spreads awareness of the importance of proper sun safety and the risks associated with sun damage. While printed materials from these programs were able to increase sun safety information recall by parents (36.6 percent with GSS vs. 16.7 percent without GSS), GSS did not result in greater sun protection for children at ski and snowboard schools.⁶

To provide impactful sun safety education, information must be tailored to the correct audience. Here we present results of a survey of snow sports participants’ opinions and knowledge of sun safety as well as offer education strategies to meet the demonstrated needs of specific groups.

Methods

We administered a survey to a convenience sample of snow sports participants (n=50: 34 men, 16 women) at a ski resort in Washoe County, NV to further characterize the populations most in need of sun education and determine how this education should be composed. The survey (Figure 1) included knowledge-based questions about sun safety, personal history of sun exposure, questions on a history of skin cancer, perspectives on sunscreen use, and demographic information such as age, gender, and education level. Exclusion criteria included anyone under 18 years old.

Figure 1. Survey document

Results and Conclusions

A total of 64.7 percent of snow sports participants reported at least one sunburn in the last year, nearly double the 2010 adult average of 37.5 percent reported by the CDC. Based on this data, snow sports participants are most definitely an important target group for sun safety education.

The average number of sunburns over the last year did not vary largely among snow sports participants with different self-reported skin types (Figure 2), suggesting that people of all complexions could benefit from further education and skills development regarding sun safety. People who reported that their skin burned easily and that they do not tan, in fact, had fewer sunburns on average than people who reported that their skin burned rarely.

Figure 2. Average number of sunburns among different skin types.

Figure 3. Highlighted survey results by age. “Sunscreen breakdown” and “apply every 2hr” describe the percent of correct responses per group. “Skin cancer concern” and “4 or more sunburns/year” reflect self-reported individual information.

Data were also analyzed for trends among age groups (Figure 3). Participants in the 18-30 year-old age group had the highest scores for basic sun safety knowledge: Almost 88 percent knew that sunscreen broke down over time and 75 percent knew to reapply at least every two hours. However, despite this group’s impressive understanding of how to protect their skin, 12.5 percent had four or more sunburns in the last year and less than half reported a concern for skin cancer. The disparity between knowledge and action suggests that, in people 18-30 years old, outreach efforts should emphasize the consequences of long-term sun exposure while increasing sunscreen accessibility and education about other methods of sun protection—such as the use of hats or protective clothing.

Of participants 31-50 years old, 73.1 percent knew that sunscreen broke down over time and only 59 percent knew to reapply sunscreen every two hours. While their knowledge about sunscreen was lower than the 18-30 age group, only 7.4 percent of people 31-50 years old reported four or more sunburns per year. One possible explanation for fewer sunburns despite the lack of fundamental knowledge of sunscreen use is that people in this age group use other methods to protect their skin, such as wearing long sleeved clothing and hats or seeking shade. Education for this group should focus on the facts of sun safety as well as alternate methods for sun safety, further developing the skills the group is already using to protect themselves. It is important to note that 66 percent of people surveyed in the 31-50-year-old-age group reported education as high as a doctoral degree (MD, PhD) and therefore may not represent the general population of 31-50-year-olds who participate in snow sports.

Of the participants in the 51-70-year-old age group, 83 percent often worry about skin cancer and report rarely having sunburns (None of these participants had four or more in the last year) despite frequent snow sports activities, indicating that education should focus on how to identify potential skin cancer. Education could possibly come in the form of the ABCDEs of melanoma, as well as guidance on how to perform a proper skin check on one’s own body.

It is clear that education on sun safety is not a “one-size-fits-all” proposition. While people would benefit from receiving and understanding all the information available, it is simply not feasible to provide every patron with all the available educational materials at our disposal. Due to limited time and resources of both educators and patrons, it is crucial that sun safety education be concise and tailored to the specific individual for maximum impact. Ultimately, we found that 18-30-year-old individuals may benefit from education on the consequences of long-term sun exposure, 31-50-year-old individuals may benefit from education on the basics of sun safety, and 51-70-year-old individuals may benefit from learning how to perform a self-skin examination and when to contact a health care provider for further examination. Future work in this area of interest should include more data collection at a variety of ski locations across the country in order to get a more representative sample of snow sports participants.

The authors report no conflicts of interest or financial disclosures.

1. American Cancer Society. Cancer facts & figures 2013. Atlanta, GA: American Cancer Society; 2013. Retrieved from: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed August 1, 2019.

2. Quatrano, N. A., & Dinulos, J. G. (2013). Current principles of sunscreen use in children. Current Opinion in Pediatrics,25(1), 122-129. doi:10.1097/mop.0b013e32835c2b57

3. Centers for Disease Control and Prevention. Sun-Protected Behavior Rates. https://www.cdc.gov/cancer/skin/statistics/behavior/sunburns.htm. Accessed August 1, 2019.

4. Pinault, L., & Fioletov, V. (2017). Sun exposure, sun protection and sunburn among Canadian adults. Health Reports,28(5), 12-19.

5. Crescent Ski Council. SIA/Physical Activity Council 2013 Participation Study. Retrieved from: https://www.crescentskicouncil.org/2013FallConfPresentations/7-2013 Participation Study_Full Version with Appendices.pdf. Accessed August 1, 2019.

6. Walkosz, B. J., Buller, D. B., Andersen, P. A., Scott, M. D., Liu, X., Cutter, G. R., & Dignan, M. B. (2015). Translation of a Ski School Sun Safety Program to North American Ski and Snowboard Schools. Health Promotion Practice,16(4), 560-570. doi:10.1177/1524839915577081