Research article
Weekend Sun Protection and Sunburn in Australia: Trends (1987–2002) and Association with SunSmart Television Advertising

https://doi.org/10.1016/j.amepre.2007.09.024Get rights and content

Background

The Australian state of Victoria has run a population-based skin cancer prevention program called SunSmart since 1988, incorporating substantial public education efforts and environmental change strategies. Trends over 15 years in behavioral risk factors for skin cancer were examined in a population exposed to the SunSmart program. Whether outcomes were associated with extent of SunSmart television advertising was then assessed.

Methods

In nine cross-sectional surveys from 1987 to 2002, 11,589 adults were interviewed by telephone about their sun exposure and sun protection during outdoor activities on summer weekends. Analyses completed in 2007 adjusted for ambient temperature and ultraviolet radiation.

Results

Sun protection and sunburn show substantial general improvement over time, but have stalled in recent years. Use of hats and sunscreens significantly increased over time and peaked during the mid to late 1990s, compared with the pre-SunSmart baseline. The mean proportion of unprotected skin was reduced and was lowest in the summer of 1997–1998. Summer sunburn incidence declined over time and was 9.1% in 2002, almost half baseline (OR=0.53; 95% CI=0.39–0.73). Higher exposure to SunSmart advertising in the 4 weeks before the interview increased: (1) preference for no tan, (2) hat and sunscreen use, and (3) proportion of body surface protected from the sun.

Conclusions

The general improvement in sun-protective behaviors over time highlight that a population’s sun-protective behaviors are amenable to change. Population-based prevention programs incorporating substantial television advertising campaigns into the mix of strategies may be highly effective in improving a population’s sun-protective behaviors.

Introduction

Skin cancer is a preventable disease caused mainly by overexposure to ultraviolet radiation in sunlight.1 Skin cancer is more common in fair-skinned populations exposed to environments with high ultraviolet radiation levels.2 Many countries have concern over skin cancer rates,3 and Australia, with the highest incidence of skin cancer in the world,4 has been a forerunner in its public health response to this disease. Affordability and access to holidays in sunny climates,5 variable fashions favoring dark suntans,6, 7, 8 use of artificial tanning salons,9, 10 and atmospheric ozone depletion have the potential to dramatically increase a population’s ultraviolet radiation exposure and consequent skin cancer risk.11

Strategies implemented to minimize the human cost of this disease began in the Australian state of Victoria in 1980 with a modest public education campaign. It included television advertisements that were aired principally as community service announcements and incorporated an animated character called Sid Seagull spreading the message about how to protect one’s skin with the use of a shirt, hat, and sunscreen when out in the sun.12, 13, 14

With the benefit of additional funds, a multicomponent broad-based skin cancer control program called “SunSmart” was launched in Victoria, Australia, in the (southern hemisphere) summer of 1988–1989. For nearly 2 decades, the SunSmart program has provided public education about skin cancer prevention and promoted structural and environmental change in schools, local government, workplaces, and swimming pools. Paid televised advertising campaigns have been an integral part of this ongoing program, serving a role both in public education and in keeping sun protection on the agenda for the wider community. Aided by formative research to develop campaign messages appropriate for the primary target group of young adults, the first paid media campaign began in the southern hemisphere summer of 1988–1989. Early SunSmart media campaigns used relatively simple messages to raise public awareness about skin cancer and how to adequately protect one’s skin, while later campaigns featured graphic commercials portraying the consequences of having skin cancer.

Although there is growing evidence of the success of health promotion media campaigns in influencing behaviors,15 there are no long-term, regular, and systematic population-based studies of mass media for skin cancer prevention. A recent systematic review of skin cancer interventions concluded there was insufficient evidence that media campaigns alone were an effective approach to increasing sun-protective behaviors.16

Given the long lead time to influence skin cancer rates, monitoring the population’s sun-protection behavior and sunburn incidence is a critical process measure in assessing future program impact on skin cancer risk. This study examined trends over time in sun-protective behaviors of residents of Melbourne, capital of the state of Victoria, Australia, and the effect of SunSmart-paid television media on skin cancer prevention attitudes and behaviors in the context of a long-term health promotion program. A feature of this study was the use of a unique population survey conducted over successive summers developed by Hill and colleagues in Victoria, Australia.17 The current study hypothesized that improvements in behavioral outcomes would be seen over time and SunSmart television advertising would be associated with improved behavioral outcomes.

Section snippets

Survey Design and Participants

A cross-sectional survey of residents of Melbourne, Australia (population 3.6 million in 2003) was conducted over nine discrete summers from 1987–1988 to 2001–2002 inclusive. A market research company conducted telephone interviews on Monday or Tuesday evenings (or the following days if Monday was a public holiday) over 13 weeks of each summer from December to February. Approximately 100 residents were interviewed each week, so that a composite population profile of reported sun-protection

Change in Tan Preference, Sun-Protection Behavior, and Sunburn

Table 1 indicates a pattern of improvement among respondents’ tan preference and sun-protection behaviors compared with the period before the launch of the SunSmart program, but with some leveling-off in more recent years. Table 1 shows that the adjusted odds of respondents wearing a hat increased (relative to 1987–1988) until 1997–1998 (OR=2.86; 95% CI=2.30–3.56), while use of sunscreen (SPF 12+) increased, then peaked over two summers in the mid-1990s (OR=3.53 in 1994–1995; 95% CI=2.76–4.51;

Discussion

These results highlight two important and novel results supporting the initial hypotheses. First, long-term improvements were found in a number of skin cancer prevention attitudes and behaviors on summer weekends. In particular, large increases in sunscreen use and hat wearing over time were noted, with a peak during the 1997–1998 summer, compared with the baseline survey summer. After 14 years of the SunSmart program, the adjusted odds of sunburn incidence were reduced to approximately half

Conclusion/Recommendations

While encouraging for skin cancer prevention efforts, these data highlight that a population’s behaviors and attitudes toward sun protection are in a state of flux and thus amenable to improvement or decline in response to prevailing influences. These findings suggest that long-term commitment and adequate resources for population-based skin cancer prevention programs, that include televised media campaigns and strategies to monitor and evaluate outcomes, may reduce the population’s skin cancer

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      For example, early SunSmart advertising campaigns raised broad population awareness of the need for sun protection during outdoor leisure activities and subsequently about the dangers of deliberate tanning (Dobbinson et al., 2008a; SunSmart Victoria, n.d.; Iannacone and Green, 2014). More recent campaigns have targeted high-risk populations and prioritised promotion of skin cancer early detection and protection during incidental sun exposure (Dobbinson et al., 2008a; SunSmart Victoria, n.d.; Iannacone and Green, 2014). In 2007, SunSmart's slogan was updated to ‘slip, slop, slap, seek, and slide’ to promote the use of five forms of sun protection (shirt, shade, sunglasses, hat, and sunscreen) when the UV rating is 3 or above (Cancer Council Australia, 2019b).

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