ART~I(LE

Trends in Sunburns, Sun Protection Practices, a d Attitudes Toward Sun Exposure Protection and Tanning Among US Adolescents, 1998-2004

-De pe rtme nt of E pld ""fnioJogy ;a nd SurV€'i llance Re SE:a rc h, Arne ric a n Ca n cer So c:~ely, Atla nta Georg ia: bD~rma [oE.pidemio I og y. Un i [j VA Meu lea ~ Ce mer P rovrde nee, Department of DerrnatologYr Rhode lsland Hospi~at Providence, Rhode Island; -Departrnenrs of Dermatology and Community Health, Brown UnJversity, Providence-,r Rhode Ilsla,nd; uRo~l~ns School of Public He.i8~rhj Emory llniversirv, Atlanta, Georgia

ABST'RAC,T

B,,A(KGROUND. Sun exposure in childhood is an important risk factor for developing skin cancer as an adult Despite extensive efforts to reduce sun exposure among the yuun,,gj there are no population-based data on 'trends in sunburns and sun, protection practices in the your .g, The a.] rn 0,$ this '5.1 ud y was t.o descrlbe natlonall y representative trend data on sunburns, sun protection. and attitudes related to SU,f], exposure among US youth.

MEfHODS" C ross-sectional telephone surveys of youth aged ill I to 18, yea rs in 19'918 (N = I l 96} and in 200.4 (N' = ru, 613) were conducted using a 2-stag,e sampling process I[,() draw populatlon-based s2IJnp,I,[C's.. The surveys asked identlcal questions about sun protection, number of sunburns experienced, and attitudes toward sun exposure. Time trends 'were evaluated using pooled logistic re gress i •. ~n analysis.

RESULTS. In ,')I004~ 69°/~} of subjects reported having been sunburned during the su rnmer. 11{ ,t slgnlficant lv less 1 ha n ill .1998 (7.2 °th). Ther - .. 'was a slgnlflcant decrease In the percentage of those aged II '[0 :~ 5 years wh 0 reported sun burns and a nonslgnificaru increase among the 16- [,0 lS-ye.ar-oJds.. Th .. e proportion of youth who reported regular sunscreen use increased sigruficantlv [ro.nl 31 °/01 to 3'9,%. Little change occurred in other recommended :S.U[[ protection practices,

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(ONCtUSiONS." smai reuucnon In sunnum requency anc me est increases In sun

protection practices were obse rved among you th bel ween 19'98 and 2004~ desplte widespread sun prote ction campaigns, Nevertheless, the decree Sf' in su rb urns among younger teens may be cause for optimism regarding future trends, [Overall.

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,[, :lei, e was J a tnc ,! ,I rmter p.l Ogl ess in rmprovi ng SLUl prote CHoOn pi acnces a fie

reducing sunburns among us youth between ~ 998 and 2004.

IN'Ww.pooiiiiii1ics.org/r:gliil'doill OJ 5421 peds,2005~ 3l 09

dot 1 0.1 ,S4,21peds200S -] 11 09

O[her than rhef nil n<:~al support: ~m' da~a oollocri'on~ [he. funder did f10'~ p~ay a! role ifi '[he' de~!g n and rondw:r of the 's'mdy; dala col~e<tl0 FI_ manaqernent, ,al1a~~ls, and imerpretalion o~ the d;na; Of in tJh€' preparstlon review, or ,a~prollla~ ef lh e ,i)r[icie,

The American Cancer Sociell staH and

cai rivestEgatms W€r~ involvffii in. 1 or mor:re· or rhe roUowl 119: d~~rg i"IJ and 'OOMUCl of tlh@ smdy,; data (oll!Z!ction marlii.g,L@merl't; analysJs. and 1 nrerprerauon or me data; snd prepi3irar~ioF'h1 relJllim~ and ~Dprovoll, of the an~cle.

Dr (oklkinM:les had full ,a«(e)'~ to ,a,11 the data in th@ st.udy and 'taikE's ~spor;sibjlily [(!rth@ ~megFu~y of the da'~ illnd [he' aCcm,acy of the data arh2!'Iy:5i5.The ~deas and o~'ii!"ilons expressed :here~n are those 0:[ the d uthors.

1K.~y 'Words,

skin ,canc:.er, :)kin f!leopl!til~m~ 'p~\e\leni~ion

a nd (omFOI~ sun e~posureJ sun protection, Sli n bum. s-un 5(lreen ~gel1u" ~dole~{em, epldern io1ogy~ hl!;!'.a~ttl :5UII¥ey!i

Abbrevii~~ionl:;'

:SP~ '1 S., -su n p~te(tnoi1 f.a([Of 2: 15, (1- confide'fhr.:e fnEervai

Ac(,epted 'fm publ1(iltioo .Mar 17~ 2006 Addf'E!~ i[orr'J!ispmld~n(.e' (0 Vilmi (O~lnides. PhDj l!)epa filmem Epid@mi(JJr,:~}I arK~ Sl.:lrveil13nn~ Jl;@~~rJircit A~rh~I'rCitn (aJfi(!er Sociei[y. '~ 5,99 CnftDn Rd. iNlE~ A't~ar!,[ii. GA 3D319-4,.2.S t. E.~mail~ vctJiti IlIt@c:anct:'i' ~or.g

PEDIA TRies (I1SSN Numb?ls~ Prin!~ 003 T~4005; On~llIli~1 ~ 008~,2iS.)! Copyright 0 2(()6 by ~he' American AG;aderrny of ~ooFfjmG

PEO~ATR~C5 Vol u m e '118,. N u m ber 3. Se prember 2006 85,):

MORE T11:AN I milli . In. cases of basal ce ll or squa. . rnous cell carcinoma and 62 1 '90 cases 01: invasive melanoma an:' expected in .'00,6 ill the' United - rates.' Oil ~: h, se, only mels ',!. nna is, included In (, nee r stat istics published each year b~' 'U:,,'UUlot registries. "I ~ III ugh basal cell and 'SqU2U-lfiU<, cell skin C2Ull( rs (k ~rifHjni()(ytt~ carcinoma c') ,ar'le' ~11I i,g,hJ~, It reata ble, they accou nt '£1. U" eonsiderable n10 rbidhv a nd health care expendit uri es. Purthermere, the lncid nee of both melanomat-' ti nd keratinocyte carcinoma+' ha we bien increasing.

'E' ''''-''' '[";.:a. ns 'I 'Il: ~'p, ;II:.I']J~ ';1 le ~" ~1 ~]. 'Ii; I ii'"Ii;[ ~1"""5'I, 'I' a '111 d b 'I o to ['1" if"! I 'I "V:"I' l.p, n'" ,''',;H

" A.,[!l.llL.,;:J11·V~ ~ i" .. ~~!I~,'.'_'i'l!.:.i~J"[~(;~" I(,u,,'.,_ "I"'I~J "l:j,J!LC:" I .. '·.,,·,IIC~~!~~

impli cates ,· .. un ex posur as 1 h e prin c ipal c~ us cd' [):f un e la - noma and keratinocvte carcinomas ol ~:111.al s,k~~ ",i"S: An esrimated 8.o°/~ of all ····krnn cancers are caused b. 'UV', olar radia'l:ion~'s Despite e .. ide nee that excessive sun exposure ln childhood com rlbu tes ~,O the risk o sk in I a~' .• ers Ia ter iln U:flet9 sunburns, which are markers of Intense UV exp O'SU'W-f, rernai 11 .. ·.O]nn1011,. especially anton ~ adoles-

I I lli.-.r·

o~nts,.lO-12 Several re .. · '.:- n ~ studies also high ~igh t rhe ot igo-

lng inadequacy of reported sun protection practices

a '1'II"rIi' "1iI"'IIg -:i dolesc :til mlf" ~ :t-l "

_ 11 ,Jll~'! . WI~,I::. l!t_~ll~. I '." ~~.j "_I, ~! !1~~I:i' - -

Most governmental c nd nongovernmemal efforts to prevent skin. --i ncer i,n '[hie Unlred States have sought 1[0 change the individual behaviors of pc"' rents and chil =. dren .. 16~1'~ wlrhou rn 180 e(u·. '0111 i ta nil emphasis on su n pro-

tection pollcf -s such as th ose used ef 'ect ivelv in. A ustra-

, .

'] "I ~ ''1;0 'F"l'I'·'~" '11' e rm ~'\ IIf" 'I! 'iii J1 A 1"';6'j, ]1 a' v ~ be ~]1 '11""11 ;[" ve t ~~ m ""HI 'I C-I>l~' ,1'0 rts

I ,,1~I'i'=" ·!.tl fL".:· Jj,' l~iU;~· .,. I~,,!, ~I . ...! ~ _,:_I(;_·· .... :·I~ _ I~'~ '" " \.1' ,~j'J ~~ _~l~l ",II;IIU, , ... : I~~.l .. ·. Ib.J

'1:0 ass'ess [.11(: •. ".fft:,.~Hv~ l}fSS of Sli n ,pro~ec'fion In~:e rven·, '[.[0115 in youth n:atrnOI, ,wIde or '~o n]leasun:.~ th,e'ir ch.aw,l"~i 'S in

~,t'~']"'~'ll dlloiUS' ,to''Ii~J''.o:''iI ~~r~ l' ii ~I i'l lii)"I"'O" 'il ;F!:ii'CI! I' 0'1'" -:=!i1'if'flI..r:~ 'j! ~ 'I"' "11 :;1 ~'lg:JI ,11;j1::1it 'r' "11' ,.II' ii;']I"1j,p

!;',I ~,~,,, I~, ' I ~""'" I!!, 'IIr'f "u "",:i II!;, II ill ,~" , 'I~, ""- ,11..1. ",I, C!ll1I ,III d !Il ~L .1,,, , ~l,~' ~ . h .• ;),~,!II ~' ~ '!i;,... I~"A!!!;,.

sll'hsta W1 HaJ dWS,i},-' bu ~11erlj ca tl,Se'(, by' e:JI(c,t!:s~"Jvt',lI n It: xPOS,UT'If'm Thi,·, SULI d'I' cOnlpai"ed th,e ~rl.,'quf'n.·~. 0_' s,'Unburn' a.ndrl.i,~ u lies £'U d l'c.'ha,,~,o'rs r,e:g~i~n'di'ng Slfl prolecH nl h'ill ,2 nalionalJ~l ]"'!t;TU"fS'·. ml~ative SL1 r· . ey's of 1, I .. , Ilo ], ,"','-'ye'a r-' I ~I,ds c(Jnduc~~I~'(" ~'ru, n 998 ,an. I 21004~

METHO'DS

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Th,e' ,A,:tn,t::,riica n 1 •• 8 ~ I (,,(:'IF Socle~}f cond ucu::d .2: popu Ie '[ ruon = 'bas"ed" na.n:i.ona,~ I .. " '-OS'S-Srt'Clloll,al, SI!. ,rv~ys of non ins~i~: I]] ~ ~j.on,aUz!e(;t ch i Ildr(~n", ~ m '[0 1,8 ~!ear:s of iag!f'i Uv~ng WIll 'wlrue COWlHn,ental 'Uniu!"d St,al(~"I, 'Th,~ htiti"a] Sun ,urvc'y ~, \r_as con d u c~: e d fro U1 Aug Ui $,1: 't () ~~ O'VeTl1 be r 1 '9 '9 8 ,a n;::1 'S1~Hl.lP h, d

'~I ~I 9"6 'b ,,- -.,- . .-:1 I~".,~I !- 1~ 'i· '. . ," ... " Cii 'S'""--"" .-"~ II ,- - So, r--r-

W' 'w' _ oys an u gu ~S rnL ,~l.rus ,age ra.n,glt:'., ,IX yea ns ~I~n. [ie r, :c un

Survey l~ 'was, (ond'ucted in A.Ug'LlSt t,o N'ov,Jou:lber ,21004,

"':ii 1~ ,("""'Ii -, ,.- '1 e '·d" ~ 6;.-. ] 'J! ,'" ~("],",,,o" i'1"Cj,iGil" !"iI1'-["~ ,',' ,~,l. ,-, r- .. 81; . ".~,. U ""

,(;1,1.. u' ~cdL]l, Ie. j, ..•. Jl J ,I, I-~],_:.L'.L ;~"i;", h S til 11.11 SCi 1:11e age ~,an,~,e"

." 01: h Sll rve y". :s used sl ~n 1, ~ a r '[e~ e~:d:l 0 n e , .. b, '~H!d 's,a r:n 'I) ~ i n"a

. im, ~ b

nl,11i I} Ol~ 0'1'1 0 (II ~, ,;U' ""'Ii' m,' " . ;t'J' ': - ,- 1:1,"' - (pi - - I - iii ~ I ], II, I ~ c; ,-,

",e, 1~,,1 . ·l!l.Jl .J ."~} .' ~,~ - ·~a~,e :sa nlipl,Hlh' ~n,el~ wlO(!O~O,g,y \iv,a s

uSled to obta.in c rc'p:n:':SC'lI1lallru: Ie sarnp~e' of 'U::, hO'I;I,'$' ,~'ru ·.I,d'S whh H~ h~~~)hon'L:s S,U",. ,('filed by' 7 'U'S n.~'"jji[Ul' i, 11(. 1",acl,er~i'lJed b1l ~ 've~s of ul~::r,~ vio 'el 1"!adwatio:n,.:2~ At ~he inw'l wal,(iont.a C'~~ I~nl aduJl [nfOr~lnanl 'Vva,sa:sked i.f th,er'f' w(:"r~~' iu:,t~hHdren

b . 'I I' '~ m d] 8 '].. '. -~] ]'~ d

.~·-i'! ... ,' ,.-. "J'" ",I '." "'-":'I-'l~ 1- .. ,- .. :;. .....

e~,ween ~ le ag,e.c (1, '~' '_ (tni" "I' I IVU1'lg U"] Ll' lOU < C .10 '.' ,

m,n hOUS,tholds 'w"hh: :1 chiJd hl lh~,s ,age range" h,~ or sht \NftS s'el,e("l.,ed ,EIS l ih~' ~;c]1[nden.L In hnu,s,(;;'h,')[d. wh h >'~

e liglble I. htld, the t ch ild with '~, he 1.11 o~ t r cent birthday wa: selected, Th,'E parent or gu a rd lan ha vlng 'prh1121 ry ca regi vi ng respcnsibillt ies was se lecte I as the parent respondents.

B,o'~lll " urvevs asked idei '~j['a~ que: tlons about sun pro'~, e C~ tin n b,;IO 1·~"V:j 0 I'S,,. : ...• U n ~ . [I r n e xperl en ces, lEI. :11 _ <~'U n protec-

rio n a '[ ~ i ~ ~~. t es. Tria rn rru ed inte r'. ~: "\NiC~' ~'"" a J 11.1 'il n i stered the survey .. using . tructured telephone que', tlonnatres. 'Ea-ch, interview '[ ook an a verage of '~5 nl in u res to adm inister, Up to 14 attempts were made to reach 1. h e eligible particlpa nt . .I nitta lly, the in terviewer spoke with t h parent or gua 'dian to' complete a pare 111- ~'""pe'· lfic survev at d ga ther SUo i. demegraphlc informa '[ linn and sun protecrion pract w.· e s hr the PCi rent. Thien . he select ed adolescent completed the iruerviei -. ~ IQ ua ~ i~, ~/' .' (11-_ trol logs were maintal ned '[ h roughout the ". -_,at.a, 1(.0 ~ lect ion period. and data '1;'~1l,1'Y' error rates were low «, (/0)" Standard resp 0 n Sf r 2U e I orm ~l~ a s were use d '[I, ') C al c u late th e scree '111 ., lng, refusal, and, reSp0]1SI::m1 rates for ~ oth surveys." The screening rate <, were -..,.90% 0[", both surveys: thts indi ... cates that .. ~. high percentage 0.£ the eligible populatlon was, successlully sere ened fU,[i age and 1,'U.F.1 'ho~d •. 'I,w,gi-, ltiJh.y' .. 'T~'u~ percentage 0:- h U seholds h~ \1v,hk h 1i3 parent and child Ide lined or. '~l e parer ~ le "'Unlei;i. Inr both to pa rt icip - te wa :J! 5 °/0 in :~ 998 iU11 d ,J 71@/o in ., 1004 ~ T1m. se refusal rates seem high, because a refusal could occur bel! ore 'l he erie en ing process bega n or '" t an Y rime during the 5 ere e :11.1 n g 0 r ~,:11 'U:~ rv:i e"wi 11 g P n) C-~ ss, rll ,t ,',"j :n,a, ~ n:~:splonse :r.a ~ e·- i' d r: Fi fi,,~(1 as the perCle]] R~ a g,e ') f 'I he (PI~JS,S ~,b l'~l) Ie ~ ig rub'] e '})oJlulafiun whoc'onlpJ,ened fh,{.10 i,n'u:~rvie"N:S~, l,;'vet',e' 5;8'%' h1

199'8. ,a rld . ';-J,o/,o w:n .200.4..; th"e: '~ovveir :r';{~ 'llone r,cl'~e in 2004 'wa', a "l;,~,(~edl b~, ill ~a:rgl r 'pro'por~iiu'll ,n.r 'It:'II· ll,hlone' nUI:l~!'~' hers wi [':11 u nick ,.~:,e nnined s'[",u [lll,', I( --. 2,,8°10)' ,a'S ron1par,ed ',Nwth fl.lc ~n'npol.rl won of t.f:,~L:pl· ~In t' n UJn bclrs '\N'Hll un de-' '~:e:nllin~dL!l us Oe, rll1g~ no lanlNl!r' in 1998, (1.3,%)., Pa rl ~Cipal]()I,' ria ~t:S :in randorn, -d 19l1 d'ia.1 lllg su rveys bave beell re]lor[ed to range fronl 2.2 'Va l'() 70tVo,; wi,'[h a lnedia:n o [ 5 0 %1 .' I n Itt: ce n ~ y e'oa.l,-S.. die'·. '1,] n 't:'$ j, I] res:I~{ '. n sle ill" aT es i, n ran ... tunl, .. dig,]'~ di,~,~.in~ survey." hl~" '\!~ b~f!n n!p,oIl"Ied~ld '1:1] ~hi :n~l or'L, '\f~U~~' _:.ocu'Sed '~he' ~ ~~end iUl,a ~'f:$~is, 0111 ~y 0111 '(he you ~h dJata,~, '\tVll _lr';tl': ,ilna l ysii .... 0_ pa l~~n m, data vviU 'fu f' the sub}el"'~ 0 u~,ur rel'orn~,.

MJe\8SUf'!l!S

Su:'bjecE, "v~]"'e' ,askt'd a.bou ~ f~}t:ru r ag,t'" g!t!'n.dl~r~ a nd race j' arnd t ser~es of ~rt2H~st]0l1S n:~laru:d [0 Wlldi,vrnd.uals~ :1,:b,iE',notypic sus,"'~'p'[]b:iii~y In the sun~ A v'~llrud" led rulle.asure' of s,un.,Cl1,si.l ~\lru'[ ~f·H was, used l.o ca h~'g( I~ 'i.zf' su ~~,ce'pluonity ~,n

lit' 'II 'III 'n- ;I.J;' '!if 1'" 1')-' 'I "L 1"'1 ~ 'I) ~ II:'" I ~)'1II1-' 4' '~r'ii ~l' ;j1:!!"1C" 1'\ -[ '" '-I"ii. ~II' r' . -~l:=i1' 1" ~ ,[", jl:'iT ii' S~' "II C· ,e"' C' ~I. .. ;; 11'lI1

,JIiI!U """' J'\,.r'!Ij, I .111.. , . ·!tll ;11'-1, ,~"!!! '_' '_' ~.j' Ii, 'I;;..,~ _ '1;.1' J ,\I' ~ .... ' .. I~ _ ,t.!, I! (1i _, ...... , m·lt, I. J!i., .:.1;1li\, u ~

rrar~ i,on ,a rU;:'!i ,- hour or ,exJ'O'"u in ~,o '[ hie ~:U ~~n:n1,ler s,un (5;en'Sw'[ wvw'[ y '[();IU rru,bt~rn t s'kln r'e'h5"~Jon ill I [I 'r re ];ea.u:~d le'x" 'pos~' n:- 10 ~he' 'u:n1nlu'~r sun (e.asl of.,kin""~s ~annwn,~ ,al~,n,· rnly)i' t~lei 11(J'lt: ~'a'i coloT 0,1 '~lle 'skill .. a:ll.d ~:h,e natur,a~ ,(oi,(")r of 't he h,~ i: r"

Sllbj,cc~,s w,ere c sk.e,d, ,4 'qlJesHuns 10 dClerrnin,f '(hit,

a,Vlt'ra"g,~ nUI'l1tl~'~; tJI.' hours p~r '\iVlt~ek spen~, uurdoorn~s be,,,

tween 10::00 A.M and ,4::00 PM, OIl weekdays (luring, the recent summer, the average number of hours per 'week spent outdoors between 10:,00 AM and 4.::00 PM. on weekends during the recent summer. the average number of days in the past 1.2 months spent at the beach between 1'0::00 AM and 4:00 P'MJ and the number of days in the

past 12 months spent at an outdoor pool between l 0"'1·"0 Q' A M' a 11 d 4'1 .' '0' '0-' 'r iV" .'

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S ub j e cts we tie' a, sked 'wh ie't h. e r the y ex peri e n ce d. a S II n ,= burn (deli ned as any reddening 0 - the skin lasting >: ill.2 hO~lIS.,~ received from being nul. ln the sum during the recent summer and, wf SOr the number of' total sunburns experier ced during 1 he SllHl1111 er. ,A, follow- u:p question asked those who. exnerlenced su nburns 'whether thev

f: ,j;

had taken any measures 0.1 StU] protection before getting

their most serious sunburn in the summer: response options included: wearing protective cloth .. lng, hats, or st In- g. lasses: applying Sll]1, iscreen: or staying it ] the shad I~'_

OJ; __ Ill tc .;]I ..... ,I <i-,rJ =, -=~01;.- -. -~" '-~ ..... II;".J!!~'I i!!. !I.e" .. ~~~,[::i,~1~ ..... ;:).~~c~, ..... '-

,A, series of questlons were used to ascertain the Irequency of practicing v,a ri 0 u.s. recommended sun -sale behaviors when going outdoors. on. a very SlUll1.Y day during the summer fo'r > 1 hour, The sun protective practices Included staying in the shade or under an umbrella, wearing sunglasses, wearlng a wlde-brlmmed hat wearing protecti VIE' clothing. sucb ,as ,(I :1 ong -sleeved shirt or long pants, applying sunscreen lotion, and. applying a sunscreen with (I, s-un protection factor > 15 ,(SP'F

ill 5 • ) when at the be-a ch or pool. Response options for these questions used eft 5 -point Likert scale ranging from "alwa ys" to "never .11 The behavioral out.con1es 'w!e-:re di-· Cll0'~onT[z.ed into :re,gu]ar (reported :pracHcing the behav,,., ~'I £11 'ill" ':iI] 'W" ,.-~, y-" C'. O'~" 0 f' t- f;cJ '~n, \ 'it) 1..11"C 1- 'il' 'ill' 0 nT''''''' l'~ 'J- ~ -I"' "~"'e p 0 ,~",~, e d- 'p l·'~ f"

,_"j!~~ (L ...... ;W~: '':; .'. ,IL- ..... , ,L,lld,} i;;L '~'-:.).' i,;jI .i.. •.. :, ,·'Ii...:'b· L,LI", ~ . .i, •. ~ ,',W.-IL· •..• , .: ",~'r;...'-'

tichl.g '[he behavior sO'[nettn],e~ r,arelyi' ow,' 'neve'f}~

Sllbje-c'[s 'were' a.sked ,a s,erh'~'s .of tttelllS lIs'rung a 4"-'po'runt Like,rr., scale ra,ngi.ng f'rorn stromlg:1 y ,a.gree '[0 stro,ngly di.s'= agree re:fle-ctwn,g, atti,[udes a.'bOUT 'sun {!'xpos,ur,e a .. nd [an,.ning appeal, .. Atui,[u.des loward sun protecHOJll inc]ude'd 4 ilif''I11S:: .... p:rntEcth1,g ]l1Y s,'ki.n. from. th!e' 51,1.']1 1.'5 a.n eas.y way ,!, 0, C'~' a u ]'1 ;:lJ;,:W [-' '[--]1 y.:". jj :1/ ~.~~ S ~, "'iIO Ii;" 'I 111'C"C'- r' e.-·· e'n ~I 0.' :,,,[-. ~ 0 .. ·,]1 ~, I ~ O,,'WS 1l1,e·' to

!L .Ji I~. 1 ,J[ 'I;.., ;Ct, .. JI. '.' "'-It, Jj ,t!i.o' .:.1 ""_ _ Ji _ .It _ W . ,_ ~ _ ~_ ~ _ _ _ ~ _ . _ ~

lenJoy the .oui"doors withl ],ess worry~ N' Nspe'nd]ng. t[Ill.,e in [h e s,u 11. wh::h 0 u t ,an y p :rO"f.eCf ion c.a n i.:n.'c:rea. S!e" '[11 Y C'h a n ces ol[ deve101):~,n,g can,;cer" rl' and 1I:n1Y ski.n w'on;;~, 'wrInkle as 'f,ast if ~ s]Jend '~es$ '['Dn1€ '~n the sun" (OlLll' sun pro[ect:lon attilude' inde x ]$ a Su.:m.t11"a ry 111e.a.sure of [hes.e 4 her:ns a.nd h,as a r,el,iab:~lity coefficil~-nl Cron.bac.ll ,ct ='.,62)., Two od.1le,r s'tate'[]]ents. ref]'Ect ,a tt]tudes :related '1:.0 oH,tdoor Slln expO'$,u-re and lD,ay be COllS]dered as sepa,rate poten'tt:ia~ ba.rrru.ers ag.aInst red UCi~lg sun exp,osu:re:: '!~th,e' sun fee 1:$ ,good 011 ITly ~ikjnM' and #a.voi.dj,ng 'the SUll, 'takes the fun OIU of being olltdoors .. M' 'Th;f'se dw.d not corre-la.te 'with Ollr sun 'proteclion 'inde,}{" and w'ere cons~.dered se~),a,ratem'Y" Th.e '[a:n n in g :p re fe re ru::~',e f.a. ctt or :re:f1 e C~'S an. u nde r lyhll~ att ilu.'d,-[ n.a.] :p r,eJeren ce for la 11 ~ a. n d it j 'n c~ u d e d .2 ].t eo 111 S,:: !-~.I feel he.aJ.thy whf~'n ] ha.ve a nice L:j n # a ndJ J~I ],ook better 'when I hav,E' a tan" (-reliallHh.y coef:Hc.ient 'C,ron.l)cH::'h (.~ == .69').

Staitisticd I ,Ana I'ys ls

For bot 11 C'I rrvevs 'S ampli n g' 'W' elehts were ca ']- C'I '~I'n '-:Ii ted ,'t'l]- ~'m-

. " ' ... -, .:H,., ,: .'. :i~ .. ,'il,., .. "" LJII, ,'. ' r '.' -, 'oL ,1\;.'_ yot'l(, . ~'--->_,_ yi,(u,'rC'\;_, "ttllJ,

tak . .'e into account unequal probabilities of selection beca use of sample design, nonresponse, ,a.nd. poststratif ca = tion. Data management was conducted. using SA.S software. version 9.,0 (S,A .. S Institute, Cary, NC) .. 2~ S.Es 'were cakulan d with S'UD!AAN sofrwa .. re, version 9,.0 (Resea rch Triangle Instltu U~., Research Triangle Park, 1:\~ C) ~ 27' to ,2i'CCOU nt for the C0111p]e:x. sample design: these we're applied to calculate weighted ~S[iJl1,~ tes 'to make results representative of the noninstitutionelized pop ulatlon '0'1 U'S youth aged ill I to ~ 8 years old ~ Using the weighted corresoondins estim . ~,,[--,{.:!I~, a nd S: Es ;;'~1 ;10 a C,·' 'h '1l;':~1 ]·'II·'~J'e,· Y', vea 'II. w -: ,;po,

_ . __ .Jilt' - 11;.-- P '1;;,....,11.._ ~1!"lL~.J! ,--- = ~- '!;...c" ,I ,.,'ILJL ''jI , 111;..!i:U .. _ 'Ii...

present the weighted differences (change in '[he estimates between 200-~, and 1998) and 950/0 confidence intervals .', CIs) for the change in the estimates 'for the measures of sun sa Ie practices, sunburns. snd attltudes toward sun exposu re protection. and tanning. In addition 'it 0 c'a '~ . .,:.l 0'0 r~;; C"'!II Co] a "'1 ~I 1i I 'lil ']" V a 'I·'~' ':II ii';.::Ii a 'II] a ~I ~l S'~i C' of - 2: ~ - "'iI d !~I 'to' e' 51:-'(" W.r;::i ~,' -,c,:~ "'- ;e!, ,;II, !f.1, C l,llll !.L" Jl." , iC '" ,W iCllI.,!!;,,-' ,Il';, .II .. ,!i; ,W :1,1L j; " ,~. X. (;1, rn, J,' ,r.,. '. <;( ~ i' < !l.

a lso tested , for th ~~ statistlcal sig nifl C.'· ance c ],(' overa ~I'I time

11;.=,," ~'-_ ~ ..... _ = !!i, I.~~'I;;. ~!,,! 'U;Ji!!;,=~Ci_=.iJ __ =_ = Itt =' .... '" _~, Jt;d= ~.= ~.'II,...

trends (change I'll the estima res between ] 998 ,a nd 20(4) with pooled logistic reg r,e'S S'WO]1, analysis using dichoto- 1'''j''-'i n~, 'S' O'~ 'I ''It ro I'n e' s ':i; '~1 d the ke Y' p' - re d-' 1 j"""i' 0 [' 1:J'ii r ':ii ,'" ',d nl A ~ 20- a AI -

lJlll!Uil!L~'''1 "l',~~ I .. ,I·l:·~ UJL",'.:: li l!6. ,i"".'-':> _, I ,", :." Jl1 .. :l,,"·:· \-t'~(daJ' ~i),IL", I,lL I~ -."", .'~-

:~, and ru.998 '= 10); these mode Is also rested for signlflcant potential interactions between, time and selected covariares (age, gender, race, and sun sensirivi ty).

R,E:SIULTS

Table 1 lists the chars cterlstics ol youth aged 11 to 18 years oru d a ern ss 'f h f 2. S u rve y ve a. rs weigh ted to tho e 'U:S lJOpu]ation of a.do]c:~·sc'en.ts,. In bot:h surveys, partiripants, w'en:' Jil!1LOS'1 [y w'hite~ with a 'm:nean ag,e a.f- 4 years, and equ,aJly di v~,d.ed by gender" The pib.,e,not¥pic .ch.araCl.ftri:S= tics rele'vant "to 8t1'0 sf'nsi'ti.vrnrYI a.nd the :rne,an sun, sens'~= tivHy scor'es w'e:re cOlllpaI'ab~e across survey year's., 'With res:p,ec~- toO patte.rn s of s Inl. exp,osure I' ther,e 'was a re d UC~ tion ]-n, '[ue.a.n n U1l1,b,er .of 'hours .per 'wee:k spent outd.oors betw'een 1,0::00 AM and 4:00 ,P'M on 'we,e.kdays. (in ID.99ft :~ 3.0 hou:rs v's 1.2 1~l.o'ill.J.Ish1 2004·;, .p' ;;;;;; ,,03)., ,N 0 ,eh,Zlll,ge w',a.s

nOoted in th,e rn.ean, l1.un1h'er of 110uJ"s per w'e'ek sp,ent

0- "l~"l'- d-: '0" :(J' 'i-it" 'b ~ 'ii' ':"W·-"~i.t;:!!, -['"1< 1 0" '0· "0' A'" M·· '=ii iI'''il·d: 4- .... !IiliIO- i D'M" '011 we-:,iPi'k:· ~l"ll·d 'Il;'

. '.' .' .' _,-.II. "'1i\;". ,'-, 1i"...1;.,. .. ,,~ ".' .. ,., .", C;U,IL,Jl. .. u, ~; ,.... _' _' ........ " ~'!l;..,.~,!!,. ",.JI.,

BetlAreen 1998 afJJd. ,2004~, '[hME: l1~J,nlber of days du,ri,ng, the pas'~ year spent at the be,2i.'[h, i.:ncre'ased si,gnUl,ea,[11Iy frOiD 6. l' days :in 1998 toO 10.3 days in. 2004 (.P = .,Ol). Youth re]Jol'ted! sp,endtn,g, ,a.n a.'V'~rage a.f 1,8 days at the poo'] 'betwif'ifIl 10: 00 AM, and. 4J)OI PJV\ in. 'both 1. 99'.8 ,a]ld .2 004", Tinle' u"'e'n,d .inte-r(JJcd,ons 'with a,gel, gender'I' a11d Stlfl. sen.s.id,vi.n{ did not reV-f'al'l any sig,nifi,ca.nt e:I:':fe,ct.

!$:- b-I- - Ii' n Tr1end s

... un .. UII [_ ., '----._ ._.~L!

III 2004" 69~/o oJ: youth, repor~:ed 'baving had 1 .or .n10re sun burns during the past 5Ul11.m,e'-r COID,:pa re d 'wi~h 72 'o/Q 6 yea rs eznrH,.~r ,(T.a.t)le .2) ,. Arnong those ""'''1'110 'h,ad eX]Jeri-· "~~1" c··. '!~'C.-l ,~ s:· 'l~ [lib, '1'1 ]""1i'1 ,~]l·~lv·e~rag·'u, o.T .2.~'9 su nblu ru.s 'was t€·,-

L~" "Ii...., ,I £'1. l", L" .Jl . ., CI.= ('~ _ _ _ .. 'Ii;.. _

ported., (onlp,a.r!e:d w]th .J. 1 'run 1 99'8., The' 'iJnle"-,by-a:ge h"ii,t"e'r' '=iI,c'l-m·'o··ilil ip,lir'f' '-er'tiI" W"'" 'a-: 'it ~l~ crn- .' ~i'~CI ..". n,l i p' < -0' '1-), A- 1111')l1Q th~

u ,!. . , Gi.· ... ~,!!o.. W . '1;".111. __. "'_oJ' a _ ,0 ~ ,W ,[[ _ t_~l.lIIl l ~ , , ~.. " . ,'l ,.. ~, '

20M

Salm p lie S~ze (,n = '1192)

SaJmpi e Size' (n = 161.3:)

Change (2004-199S) [}if~e~'ence' (95% e[l)

~. ,I'

Age ]l~l.3y

]4-·15 Y 16~ 18'y

M,ean age (95% C 1 mea n) Gender

!Boys

Girls

Ra,ce

Wh~Te

.5.03 289 400

,40,,3 (31', '1 to 43.5) 24,.6 (21,.8 to 27.i1·) 35.1 (32.0 (0 38.2) 1'4..3 (14,.] 10 145)

536 ,44,3

624·

35.5 {32.9 'to 38.3) .27'..0 (24.S to 29.5) 37',5 (,34'.'9 'to ,40J) '14.5 ('1,j,'t31o "14,6)

-4.8 (- g . .o to ~.o.6} 204 (-' 1.3 to 0,. 1 ) 2'.4 (-' 1 .6 to 6.4,) 0.2 (~0,,8 to 1,.2)

.05

600 592

50] (47.5 to 53,9) ,49.3 (46.1 to 525)

822 791

51 ,4, (48l5 to 54.2) 48,.6 (45.3 to 51.4)

0.7 (-'3,.) to 4.9) -0.7 t -4.9 to ,3.5.)

.7

Orher

1'016 176

7'8.2 {is] to 81.'1} 21.8 ('18.9 'W 2.4.7)

1390 :r13

77.4 (J.4'.6 to ,80.0) 22,,6 (T 9.3 TO 2SA)

- 0.8 (-,4" 7 to 3. 1 ) 0.8 (~' 3.1 to 4.7)

Sun 5Jensi'[ ivity r nd ex low

Medrum

High

M,e~1l S LJ n se n s.i'[i vity ~ nd ex

Phenotypic 'Sensitivity 1'0 'sun 'e'xpOStJre

S k~ n reaction d fter l-h ex posure llO SLI m mer su n Seve r~ sun bu rn with bl isters

Severe 'S u n burn with pee'~i ng

M'lld sunburn, some t~nning

fUI'nin9 darker; no sunburn

No sunburn Of tannIng

Skin reecnon after repecned exposure '[0 summer sun Rep@.aled sun burns

No 5 u nra n: fr'eck!e,5

Mild ran

Mod er,e] te tan Deep tan

Natural skin color Very fair

Faiw

Olive Li.qlnbrown

,,..

Oil rk b rown/bl'ac ...

Su n-ex pas u re rha Fa creri Soli (:'5

N LJ m b er of hou rs per week spent outd 00 rs on w,ee kday5~ weig hted mea n i!

Nu rnber of bou rs pe'r week spent outd DOli'S on we,e, ke nds, weig hted 11le~n~

Nu rnber of days in past ~ 2 rna sp ent at the, beec h. weig hted mea n;i!

Number of days in past 12 mo spent at aln outdoor pool w,eig h't~d ~ ea nd

3'16 589 28'7'

29.,8 (26.8 to 3 :-L8) 46.6 (43.4 to ,49.8) 23.6 I( 20.9 to 26.3)

0.5 (0.50 to 0521

427 77'8 404

30) (28.1 to 314) 46J (43.6 to 49.21 23.0 (20.S to .25.2)

o. S ~ (OA 8 [0 ~lS.2)

O.9{-11 '[04,,9) -OJ (-'4.5 to 3.9)

-, (tG '--4,. 1 to 2.9)

0..0 (- 0.04 to 0.0.2)

.'9

127 353 384 156 H53

'11.5 (9.3 to 117) 28.8 (.25.9 '"'0 31'}) 3l JJ (28.0 ' '0 34.0) 14.1i (1 L 7 to 15.3} '14.0 {'1 2.2 10 17'.0)

148 529 48~,

207 230

9.5 (7.9'10 11.2) 12 .. 2 (19J to 34.9) 27.2 (14.9 to 29,.6) '15.6 ~ 13.5 '['0 17,,9) 'I 5.S u ,3.6 [0 1 7, n

-, 2 a .0 ( -,4] to 0.7) 3.4 (=0.4 'to 7.2) -3.8 ( -7.6 (00.0) 1..5 ( - 1.5 to 4.6) 0..9 ('-2 .. 2. to 4.0)

.1

286

73 291 3.25 ,202

2.3.7' (20.3 10 .2 5.9)

6] (.4,.7 to 7.9) 25.3 (22.4 to 28..2) 2'7'.9' (.25.U '[0.30.8) 15;9 (] 45 'to '19.3)

401

7'1 388 425 232

25.0 (23.110 26.8)

.itO (3.0' o 4.5} 26.~2 (.23.6 to 2.7.5) 28.0 (25.4 to 29.3) 16.2 (14.0 to '173)

1 ,.9 ( - 1 .7'[0 ,5.51 '~23 (-4.'11'0 '-004) 0.9 ('-1.9 '[0 4.7)

0.. '] (.~ .3.8 [0 4.0J -0] (- 3.9 to, ,25)

.1

163 633 146 "t114

27

1 ~" j (' 1 ,. ~9 to '16.S} 49.0 (45.,9 to 52.3) '12.0 {9.8 to 1 ,~tO) 21 .5 ( 18.} to 24.3 1

3..2 (1.9 to 4.5)

206 882. 204 254

47

" 1,,8 (10,2 'to 1.3.5) 51.8 (49.0 'to 54.5) 12.6 ('10.8 to '14.5) 19.0 (16.8 to 21.5)

4.8 (3.6 '10 6.S)

'-.2.5 (- 53 'J) OA) .2.8 (-1.4 to 7.0) 0.0 (.- 2.2 to ,3 A,) - 2.5 ~ ~ 6.1 to '1 .1 ) 1.0 (-OJ 10 .3.5)

,1

1183

] 3.2 (12,]. to 1.3.9)

]565

12J) ('1' '1.~, to 12.6)

'-1.2 {~'2..ot:o -OJ)

.(B

1112

7.,3 (0.8 to 7'.8}

7. 1 (6.7 to 7'.4)

- 0.2 (-' 0.'0 to 0.3 J

,,2

, 18.5

6.1' (5.:9 to 7.S}

1549

10.3 (9.,2 to 1 TI .4)

3.0 (2. 1 to 5. 1 )

, 17i1·

'18.2 (16.8'('0 '19.6)

1533

1 BJ f17.0 to U 9.5)

o '1 (- 1.6 to '1 ,8)

Va ri,ab~ e Per,c.e'n'[,age Wh 0 E'XJ,:H~rieno~d S'~ n burns Du ri ng' "he A men; llh ose Who Ex,p,eri e·nced S Uln bu nlS

:Sum:mer

Mea n No .. of Su rnbu fIlS

P\e,rClel~l~a 91e' Wh 0 Rep·or-ted Ap,p'~yilrn Q S U nscree n as ,aJ Form of S,unl P'lr(rt!eCil~o.n 'BeW'Ofe OC(,1ljlif1!'E! nee of M,os:('

Serh'JUrS Su nbu rn
!(h angie ID'ilfliretem ee' '1'99S~ 2w:M (hinge IlJii'FfJierelJlcl1! (IMeand '11 ssa %, 2:004,1' '~o ( han 9!e iD,itffe~en ()f!'
I . "._ .. "I"
(915% (I Di'H\er,e'nce) Mean Mean ('1i~IS%1 Clllll:rilr~'elrr'eni()~I' (gl.5,~b '(.I' Diffe:rl~ nee')
_.3.,) (-7.5 1.00.5) 1'10 ,2.90 -0.2 (- 0.6 to 0.2) 39.2 47.3
- 7,8,1 ( - 1 ,4. S to - l.] ] i 2.84 .1.69 -O.L (~(],6 to Q,3) 47.1 58.5 11.3d ~ 3.0 to 1 g"f)}
-9J'~(-17,lla =1.5) 3.2.3 3.00 ~O.2 (-1,2 to 0,7) 36.5 48.0 , 1.5LJ (1.9 to ,2 , • 1 )
5..1 (·-1 ,3 to 12.7) 3.36 2.97 -O.~ {-1 J to O.5} 30 . .6 36.6 6.0 ( -1.9 to ll8)
-6.9 t-11B ~oO.·l) 2.96 2.90 ~ O. I (~O) to 0,.6) 30.2 ~8J 8.1 a n A to l~, ,8)
-05 (-5,8 to 4,8} 3.24- .2.90 ..... 0,3 (-0.9 to 0,3) 48.2 56.1 7.9 (0.13 to 1 S.O)
-11 ~-7..~ to O.g, 121 3.0.2 -01 (-0.7 co OJ} 40.2 ,45.6 5.4 (CLl TO '1 o.6)
-.3.8 -~,4 .. 6 07.0) 2.56 2JO -0.5 (- 2J to 1.2) 33.0 56.0 22.4'" U5.6 '0 38. 2}
-2.9 r-l1.3 to 5.5) 2.53 .2.10 ~OJ ( .... lJ) -'oDA~ 29.1 ,.9'.0 'I g.~'! (9.0 to 30.2)
-3.6 t-9.0··o 1,8) 107 .1.83 - ~l~ (- 1.01 ,- 0 O. 5 ~ 40. ~ 4ii\O 3.9 ( -1.0 UJ 1 D.S)
- to ~~ 7.8'[0 5.a~ 1.67 155 - 0, 1 (- 0.9'[00.7) 46.1 ),2.0 5.B (- 3.8 to 15.4) Overa.]1 A9'er v 11-1 J

14-15 15-1B

Gender

SOy'S

G~rl) Race

VVh(e ~mll1l"hl e

Sum 5"el'Hi ?~ ity inde law

~~edium

I igh

72.2

68,7

75.1 78.9 64.3

57.3 69,6 70.0

12.9 72.0

66.0 71.5

79.4 46,g

7.3 '10

SSJ 77.0 8.5.5

51 .. '- 714 84.5

=""

00

Z 6

3 g

......

!-U I"l"'i ~ "'C

""""

i"I:',J

3

P<.'ool

P -c .01 I nteract lei n re r m (~ge by yea f"

CQi Ull ~l

1. 6-' to ~,,8-'l-f,~a:r-·{1~.d,s,;; s~u n bu rn pre vale nee iricreased bv ,6°k (P' > .:0:5); whereas c. '[ Y'ou nge a' eSt'S' w nbu rn prevalence decreased sjgniflcantlv by --S'O/!) among 1] = ~I., '~3,'-year-ol,ds a'~ d 9 ~/o In [,,-~-, '1.0. 15 -yea r-old (P < ~O I, ,; Table 2,) , In a. m U ltivarlate analysis co, urollh ,g for COIT=' tounders tage, gender, race, ,~U]I I sun s'(;nS,~ll,:wv.hy)" ,w,~ [ou,nd a positive associatlon between having had sunburns and regular US} ol sunscreen when gOi[lg uutdnors i.n th e s umm er I( da t ' n en sh (1\"'1 n ) ,. A m 0 n g 1. h use w h 0 sunburned, the III 0 st common report ed measure of pro=' tection before experlend ng the ~'lUS~ serious sun bu rn ol '[ he SUJIUn,er was appl icatiun of S unscreen I whereas uther rneas ures ol sun protection were very infrequem ~<2°/.o }I~ Compared w'il[h 1998 levels the prevalence of wea ring s unscreen before experlenci ng ~I serio us su nburn, lncreased 5.ig.nru,nc,al.nt~iY' (overall, 'rom 3'9'O/u, to " 7 cVo; ,P < ,.,00 1; Ta b :1" 2 )1 ~ DI u :d ng '~, h.·. ' 6,"" )fe~t.l ,Ir pe r ~ t). d, h eerie we re larger trends that showed hl' reases in ~~ e p r tentage 0,1: 'youth reporting 'SILl nscreen US,t~ be fCH!"~ geuing ,.1 serious

S,l~]1~]U' .rn amo 'J'; '~1II1~''!Ii~~' ,=W1(1I"~ICII '~i to m 5.', y~. :~'!;',a,r\ boys .:=111: 1IId. [

~ _" J!L ." _ ,I I!iJ!l I , " II. II, VJ;1!i;", C~,!t:!,1I;;. . ~. W !~ 'I!.J ,_ "'" it. _,. '1". =, ~ _ !I ._

rhos with morc sun-rcststaru skln traits and i, nonwhite race (Table 2:) ,.

Sun Pretectien P'n~H:lt;i't'Hi.lrl'ln!ds

Between 199,8 and l004~ there were signutcem lncrea Sf'S in the ave rall preva lence ! >r regula r (a lways/ol [en)! use 1.']1 ' sunscreen (,81[:10 increase. [ro,111, u 010 to 19 %) when gol ng

outdoors on a s.unny da'y Ior >,~, hour" Statisticallv srng=' nificant increases in 1]]:(:'" regu lar use I' f S LI nscreen we reo observed In most SUbgl;'OUpS examlned .. but these increases were greatest among ol ... ler youth (who reported the least use of su rscreens) a nd ,a n ong gj rls a td those who with medium or h,i,g] sun s'~'n~J:i~i,vil~~1 t who h,!!l d the hlg:h,es,l, 'Us,el s,uns'cr,"'e] _) '. T[,~ 'WI f,{!"a,',e W2], :res:tri,cte<c1 to whj I .. e yU!LW thl.. T',hJt~, pt:'"':r,ce~1~~~~g~ uf r~'s,pundeuls, \iVho r., ',,. porned :regu~at u'S,e 10. s:un,5C~'e'e'n 'wit_l SP'F 15 +" 'wh· •. 'n at ~,he' be-,ar]] ur 2U ~Jle' ,~l« ~ot j iid Wli 'U :hcJlgf' _ ~~o.rn, 1,998 to ,J004" IOther re(~onltl:U!ti,ded sun-So, fc' p:rat([~,1 es~,ll,ch a,s w,e,a.rlng sungla$s:~s.;. '\ivea l'ill,g, ~)rot,(!(~t,;i,v~ ,(,I,o~h i,ng I( ~orwg·' 's~,eeve shirts ur :ltornllg pa,n'u~,L and stayln,·:ID, In Illrne sh.ade wt:ne less: ('0111 nl,Q,n. 'The t,t gu ~,ar u'Sc· 0' 'wldt. -brhn.mned h"a ~s in th~~, 'I:l'O'Pi J"alion was very in,[n:qll en ~ (-".5 Q/~ i:.n ,2,004 )Ir. ,N'o nlte,a,$urabh:' J12H1S'-"' 'in :[~:'le'S,e pra(Hcc:s 'were observed, betvveen ~ 994 G nd .2 004" eX"~'eJH :WOI"' a.n ],rrn,cr~:as.e in th,e llrevalenct'.' of r,~gu~ar u'~,e u1' hlllg,,,'sl,e, ve sbliJ,ls or long l).anls. ~uTlong, 'wi ite' yotHh (P ,< .,05,; T.a'blc' 3)., Sinl-' il~ar tr~nds, \i'vere ob$erv~d 'when COll!1Jl]'aF']ng re,g,u:~ar I('a.~-, 'ways o,r ol~en)1 to c hrvays use tT[abl·' 3')1"

Trends in ,A.tlii'ttude'$,

'T~'u~~ re' \~v',a'S a S,]]laJ ~ bll,l. ','l.a 1. i s ~ ,i ca ~ 1 Y s.ig r in, ~ I 'I. 'j m~ ie rt'i,fI se ,i; n ~,' ,e' plerc,~ntlag,e ol J:',e'·IJo:nd,t'rJ ~S' \f.'~ h,,{, ,IF'IC'~) ~rt.ed pusrn [:~'Ve 121 n rutlL1.des. (,<,'1:1" m1i.gl y agr~e tJr ,d,g,l"it!lf() lowa _-d l he ben,:iJtl'S 01, '.·~.Imn prol[e'c~lo.n, (J ,,5; % i nl "'n",e,aISIC; P -< ,.05) ~ T,~ _15 i.· harruge i.n altrul[ude nlost~~' ru~ vo:l,vt:,d \ ':ihil,t yoU'~ll,. This ,charwge \tvas prinl:,a.ri1v ,~:n,Juf'n .• ed ')Y 2 aUrntucUnCi ,l.Ibell,e[ iBlbou~ [he

858 (OKKINIDES et dl

benefits I~), sun '~)~~'O't.ec~ ion (le. "protecting m,ny skit lrom t he [<,'U III WS an easy 'vvc~y to ""'tal' heahh v" and uspe'ntUng, rlme outdoors v\d~f OU~ auy S:Ul',(]~'tI~ r1I increases m

I h a' 1 ces 0 ~ deve k . rli W ,I; _ g .. "" at _ cer": Ta b ~.t:' .. ,. ) '. ,A u ~ t udes related to 'Lanni 19 ~ references ccntin . ed to be con U10n in 2004: 67 JJ '°10' I(JtJ Y uth !U ~~(Yngly agree or agree w'i rh the statement ~~I look. better when I have a ta n ,IJ and S 5, uto of

youfh st rongly agr I. ' or agree wl : .. h [he stater ent #T [I~el healthy when I have a nice tan," and across youth cha racteristlcs. sllght dedi ]'H!S In trends for these single items were observed betwe 111 1. '99.8 and .20014., As meaSU fled by an overa U h d 'x 0, '[ hese Items (tanning preference), there was ,a signlficantlv modest decrease in [he prevalence off 'IJu,] nve ~ strongl y agree or agree) attitudes (f ron] 5 6~ 5; % to 5 1 . .'4 °10,; 5,. 1 0/01 decrease: P < ~05i;' Table 4) .' In 2.004,j' the proportjon o~" youth who rep ',r[ed: strongly agreeing or agreei ng \~-fi'l h the statement ,fl the su n Ieels good on my skln" slgnlfic ~ 'll~, increased r~ l .. ,6U!o;' P < ,,00 '~,)I compare t \. il~l ~ 99, ~r'. els. .~ nd this pattern of change l vas consistent across cJI 0:£ the s ubgroups (Table 4).,

ID~I:SCLI 5,51,0INI

There have been I~ xtensive e lforts by government agencies. Ioundatlons. and other organlzations ln recent years to promote 5.'1.11.1. prorectlon beha vlors among children and ad 11 Its in the Uni [ed Stales for the purpose of preven t ing f u c u re 1:].1 elanomas and other skl n cancers. ~ ~.,~~, Un lort ~J na [ely f there has been :~ iJ de svsrernatlc e Ifort to assess the e Iect 0 I these iuiuatlves on trends in behavior. Partlcularlv lacking are repeated surveys 01 populationbasel] samples wrn'l h consl <[I( nt methodology '[0 a [Io'w' systematic ,£115 .essment o~ trends. ···\o~a, studies h,cr\~!e beien C[ ~ls;s-s;ecUon.a ~ Sllr le"\'s". t_', I~ l ~ ~,.!~~ \ ~ Som, e' oif thes,e stUd.:ifS

..

h,a\{!f' 'been rt'~knlk 1 i ~ Sf:t'll~i'~, Il.l"~'. ~lll 0'1 he:rs "n:~:re 'bas~'d on

n,Cl fio n ,8 n y f!f'preSit:' n ~,a f' v,~ $,8,n1.1} ~ e s,. ~ 0, ~ 1.11 a. nt:11 I 'h,8 d a la rg,t"' non.-[)opul,atjon--·,a'.ed~,a~l pll,e,.,I~ ~)e·lh.~ 'the' \f,a.r'iled rn ,etb .. -, o.Io~.og'Y ~ ~,I: ~'5e s 1.:1, rVt!'y:s 1:1,. 'Ie: .h o'wn 'th,at ad o,I,leSC€'nl s h,a. ·!e 10 W' 11.!~'V'le ~ () f, u n p m·o,'[.~ en i () 11 be ha v m,otS ,a n d h i:g h ],ev,~~s oi' 'Sun C'XP{)s,ul"'le (Lnd s,UnbUfl'IDs. ,Alrhou,gh '~indwl gs

f '~I ~". 'I ~ ., r . ~ d

n t~l,e's,e s,tuc~,li'S ~lave 11!)~'t n lr'h 0 rnl.aU v' ,I' hle}"Q rru,'l

a.ddress [~l'E issut: (,I' how t, uch, I. ha n,g'e' III ere has [~(CLlrred ill], 'US youths" sun l,rot.e'([lon and, sun eX]Josu:r:,l+.

Our s'~ucy !. ·QtUccu~'d da~." fronl 2 [hne p,eriods n,n :nl.u:~lJph;:" behaviora[ and atniulJdJr.a:1 end p,oin,ts. 'We found lhat tr.ends h~ us, y(],uth sun p,rtJ'[t~',cti.on, w'e:rl~ nlixed during the inue I;va.l 01' I 998 In 200'4,., The prev,aJence' or yO~JJ[h ex:pr::dcnCrnl!' gJJllburns du,ring, ~he' stnnJ. I'er was, Itig~. ,a nd ,g,fllc'r(j Uy s.ul[b]e be:l.we,en 1919,8, ~u1.d 20,04 ( ----70 o/@ h~1 ,2:00'4)1" 'Hov . 3V'f~~'" ~,~ _,c':r~' 'l . ',ere signi:fic.ant 'tr,ends of J,le· r,ea~,ing, prle·· ab:n,"e 01' s:u :nburn.s. ,cun,o,ng, yo[un,ger 1"1' 'e.n s',. ~l :i H k,e:1 y ~ Ii.~. '[ I hi, ~,g,~,,,,'specUi C (f,f n.,dl nl ary' r't:]!~U}' in rp,ar~ 1[0 ,gl;l~a~: .~;'r pa rn'en,'[,-_ ~ ~n ~ c~ie'n,>· in you,ngler ,adolif':scr.nt:s (a So ~V'e I, ~ ,it c·] 1. i 'lid, re':1 ~ ) " b eca us. '!O S,C vlc'ra] s,t u d :i"$ :i n d ~,ca.lle 1. h,a '~, I l.a fl n n,(]j] 'V ii. ~,:i '~,a; n ot" and ~la ren tis 'S un ,P J~O 1-rr;:IC t~ on be,h,avrnors [8 re re:l.at,ed ~o gre,~lt.t~r ~ .. t,Ul. prio~e-C1.rn.on lu'actrnc: s

r AIBILE 3 T're n cis ii IIIi ,the P reva h~ln"e' ,O'f' :$lJJo .. 'Saf:e Be,h'i)V'IOlr IP lim ctilc;es, WltlU!1rn 'G,oling OutdoOlrs 0 n it s'u nny. Da'~ IDu rii illig 'the Sumlmelf 'flO r ::> ~ fr[i,CNlJ r ~in US V,o' 'th" Su n Su rve~y 11 '9i9\8 ,alnd! 2004,

,App ~Y' Sllj nscre'e,n When {joi ~Ig Q u tdoors ilm Su m mer

19'9\8'i '%

200~, .. %

Charngel % ~(:ha ngle~ 95'% CU

A.pply Su nscreen Witl~ $PF '15 +at the IB'elH: h/~'ooll

199,8\r %

2004, %

1998~ 2.[)[)4],r.
"
% %
1.8, ,4.9
0_4 ,1J.
S.C 5.0
2J] j!t9
1.5 itS
18 6.5
3.8 .1.3 (h&ll~ge~ % I(Cha ilI~N~, '95% CI)

r ora ~ to ~I,e~ValwaY5) IOIal t Iways)

Age';)!'

1 ~,-13 14 IS 16 'IB

Get~de~

Boys,

Garis

Race

White Nornwt'~1.e

Sun sensH,ivit,}I index l'QW

M,~d~u'n11

H~gh

3t4 9.7

4, ~-9 ,],6.5 "11.9'

25.'1 37,,9

33_5 25,2

11_() 3(tl 46J

39A ~ ,),.8

43-1 35.5 ]3.0

30.0 48,6

43.0 15.3

13.6 ,41.4

55.6

8.10.1 I~~"O to ~ 2.0J 6.1 II f3.3 11,0 .&8)

6.1 (- 0.10 II 'I ) 9.0'- I~ 1.1'~o, ~ 6.8)

] 0.1.11 t4.D to 16,2)

Jt9 (-0.4 to '10,2) '10, 7.1 ~~.9 to 1 (is)

9.5.1 (5.1 10 13.9) 0.1 t -~.5 to 9.n

1.0 ( 4.1 to 9.3) 1 O. 7·' ~S.O [0 ~ 6.~, ~ 9.5 (l19 to 18.6)

r ote I (ofte nl always.). r ota I (a~ways)

Age~ y n-13 ~4 rs i 6-'18

Ge,mjer Boys, G~ri'S, Rae 'White

No n~-\Vh ~It"

S II.!ln 5 ns i:th~li l,' ~ ndex Low

Medium

I--lign

58.4 32.2

56.,4 19.0

614 64,,6
58.6 510
52.0 5 1.1 56,0 60,6

60.3 50,,9

50.8 S7J 69.0

53-I 59.8

52J 36-8

42_9 57)

74.9

~ 2~O' -6.'5101.5) -12 ( - 7.4 I~:,O ~ .0)

1.1 ( - 5.9 ~,O 8,.3" - 5.16 ~ - 1,4 5 to j,3)

-O.9~ -8.6'[06.8)

~,2-'9 (-9.610 18l - 0.8 { - 6.8 to S.2}

1 J3 t ~ 2.9 to 65} -14.'1 (~.26J.lO -1.8)

12 5.7

~t9 1.7 (-0.2 to 16)

5.3 -0,4 (- 5.5 to ,4.7)

- 7.9' t - 'I 7,(] [oil)} III t ~6J to 6;5) 5.'9 (-.2.411('0 '142)

5.. 1 2,,9 18

itS -(}6 (-4.4 to 12)

~tg .2.0 (-O.31,O~,.'4)

5:8 .2.0 (-1.7 ~o S.n

'] ,1 (- O,l [0 .2 .9) '~-9 (~O..7lo ],.0)

0.0 ~ ~ 3.1 [0 11) 1_9 ~ -0.3, [06.'1) ~ . 3 ~ ~ 1.7 10 ,tt 3)

2} (0.1 [0 5.3) -05 (~2.9 '[0 1.9)

C ha ~1~Jie" %1 ~,ChalngJ~', 95,%, (III)

31..2 1,3.2

,215 30.4- 41,4

26-2 38.2

31_9 30.5

34.4, 31.5 30.4

3Ll l6.1

,25.4 27-3 4- 1-,8

32.9 .2~lO

,iK! 31.3 ~KI

-fJ 1 (-4.0 TO 18) 1.9'( -c.cn [05JJ)

].9 ( ~ 4.'1 'to 7.8) -11 (-10,6(04,,4)

- L6 ( ,f:l5 to SA)

- ~ ,8 {-6,,9l'O 3.3) 1.9 t -4j 10 7.S}

0.0 l-Jtllo .3) - 1.5 'l ~ 'I loS [Q 8.5)

- S) ~ - I 3 A 10 L9)

-0.2 (-5) to S.3)

I J ( - 0.3 ro 1 S])

Wea r (Ihl,'t hi'ng

(tol" 9 'P!all1t~ ,or tong~S leeve S!hli rt:)

'1'n~Q: ~·~;~~ll

%

1004,~ q~,

(halngle'~ % (Ch~m1'gle,r, 91,5% en

]I'~19'a ZOM~
[.~' ~. : .1,.
'% %
, c I
21.8 21..7
2.8 ~~L2
23.9 25.6
19.4- 20.6
20,,8 l~la 22'.8 10-8

2'1.0 24_3 ljA

2t9 117

2")} 12.1

l6-! ,2,4.7'
20-5 .20A,
lR5 ,25.3 ,Clh1am1 ge~ %, ~C:ha rng,@,~, '95,%, (111)1

-0.1 (- 3.1 to 3;5)

-(t6 (~2.'~ to 0.9]

1.7 (-4.3 to 7,7) '~.2 ~ - G.O to SA} - '1 ,8 ~ - 7,6 '[0 t1,.O)

- 2,,0 (- 7 J 10 3.1) tt3 Il ~O.B '10 g, _)

2L5, 21}~

20.5 -l.O (-6.010,4,0)

13_0 '~, 1 (-,lt2l0,6,4)

J.9U (0.2107.6)

- IO.ll (-19'.9 ~,o -OJ.)

~8.6 3-13

iae 02 (~14 to 18)

31.8 ~ L5 (~HAIO 9,8)

~ I A ~ -,8,) '~Q 5,9) -OJ {~5, 1 to 4,9) 5,8 t - D,ii to 1 tlJ))

22'.'1 20.6 22.7

2L4, -1 J ~ -8,5, to 5.9)

20 . .2 -0.4 (- S,ot1, to 4.6'

25,,0 ,2,9 ( ~t1,,4 to 'I OJ)

Prl2v,iJlence or f~g U~lilf ~UI ~. sa fe behav.Qr pr ,3C(iceu as Jlw~y~ 01 0'11 ~J 1 -P <. .001

III :P '<. ,os

l~_7 7.3

11.1 lR9 )4J

219 ~9.4

~a.8 ~,2_,8

and reduced likellhood of sunburn experlences '[11, their

ch ~ I('~III-' .I'!j1iI_1 t ll-~~ U'!~"I' ween ~ '998··.~·' a nd"OO···· III'" ~jj nreva lenoe

.... 11 ,~ ,LL IIilII .' U Ii;., Iu " II<;,. . _ '_ ' ,,'. _ " __ '__ ~.... _" ,,,!, """- ~.Ii'!I 'Ii", ~ rn,'L , IIL'L

,cJ[ ~.' ",gul~"I,'I,}I pra trueing :1]1, asures ol sun ~U~O'[I I (ion '\ ';.!'ft; . O'\fV;; wh .. ereas opportunities for ~,igh (lntennluent 'IU'V e x pes U It see n 'n 0 have i 1) crea sed !~ i e. j, n ere: se d. nun 1. ber or days spent en the beach), l~ln,erl:.tw~_gIIY' among older

- " . - ~ ,', I·· ~, - " ' . ," . .,', - d'i 'j. -- ~", - -t" Ui' .. d .' -, ." -., 'i; " 1 .' ". ii t , ' .. .., . ~l-. .. · ,

y~JUL1~ W ouno ,(1, ~,~ rger u en __ mcrease U.1. me nu I noers

O~ days spent at the beach than in younger youth (data ,n01 shown). i Iowever, VViC lack the. informetlon to deter-

- ~ " . . . ,-' ~I' .:1;' '-1- ~. - ,.-] ,.- -~ "" - d '!' - , ",~.,.. ";:;, " .', .,,~ . -. ,. -. b ' .... .' ~' -. ': ...

~, run e w ,lie t l.e r tne tr t nc H'JJl rease m tne 11. LUll '(:.1. '5 '0, nays

," .,:0, ,', 'L" . 'n th ~f-.. Ji". 1·· '.. . 'Ii 'I . 'l'Lil! J In.-· "'. -;0;. r-'-~-'11~I'Y t, the be . !U

spe u a l III re I~J!!e die 1 ts W·, iareu !!(J pI OXU h~: Ik,O,~ ,a't . earn,

popularuv of the beach as blnlily vt:_, atlon, or more .afTord,ablc' ,al:nd I:t'f,'que:nn, u'(llvel '~n b ,C' ('l~ by old: ... 'I: '~IOU,l,h,~

L 1 (~2.5 10 ,~t n 3.5'~ ( ~ .0 [0 5,0)

~ 0.2 '-6.0 to 5,6) SA ( - 1.8 to 1 2' J6, -0.1 (~6.9 '[05,6)

Th bear h sett i ng, in pa n w cu la r, ,P rovides a g r, 'e 1 er up .. portunlty I,ur expo: ure 1[:0 intense (lrnerminent) IUV exposru,[~' and is, assods ted with extended time of 'U'\l radlanon e x '~)OS u re. ~{-'" ~7

'W't!. a Iso 0 u nd increa s ~ ng 'n '['e nds 1. n, t he plFOpt.lt lit ~ 01 ,of youth w ]JOi reported we;,aring, ',lU1S reen be 'ore . ~~"Uh-,Qi their U1,oS,l serlous sunburn and that regu la r use of s unscreen "-V',Hi independentlv associated wh h C'J( perlencing sunburn in the past summer. after adjustlng '01' confounders These Iindings. in parallel '[0 our Hndlngs of an iucreasl ni, j tren d :i n regu tar sunscreen tJS!~; as de-

tC ribed fIj'l ,;] V Iii m:on Y I - ~I rll~:;J:I[J'~:dICll iii 'I "lll·t C'~ 'I rI]lj[II-.r!li~ 'ifJI!ll l~I~f.~~ :lil ~'l ';"it r-I~'III ii'i~'il~

.11,.' ~,Ii;.. '!!;,1 UII!", A ~;I' III III i!<,1 ,1",11 00111.;, ~l', III.. C'.;,L ';jo IlL! III, ;j.'1i;. III . '",,,,, ~I :jI'~ ,_:' ,I' '~J ' 11!i;,,!!i;-

01 excessi ve U V expiosu -e ;Ci nd 'H _at. 'when~,as "nlend,j,n,g, ~o

PrOjporti:O:rnl o'f '\f'outlh Who J10tall

OilS~nJlngli,y A,gl'iei~,lj! or HAgn!le~

Ag,',le' U

- r 1/

2100.4" %

I(halngle 2004-·'] 9981- % (9S~-& (II}

,2.t[)04~ %

c ~I~ ngl~ :2CC4~ 1998! % (9'$% (~}

19981. '%

""lInif'liA. ,~,~V~I~

%

19981. %

,:2004~ %

'~'998~ %

A. [1 i UJ d es en beref [S >0 ' sun protect io~' Pr{n~tif1g my skln from the sun is an ea&y way [0 S [,ay h ea 1 thy

U.SHlgl SLU'lscreen allows me ro enlQ~ the cutooors w~tn less worry

~pendirtg - j,me au [d eors witho ut a ny sun PI o[ec! ion (a n i I"i;Uf'iL5.e mv c han.ce~ o~ de\N!lopi ng cancel

IAv s in won"- Mllfln1~ e as as- iff I spe.nd less nme in i he' UHl

l'lm protection index t 1) values !S2 Atilt udes O!1 olnd DO~ sun ~ pos iJre

111 e S un eer~ good 011 my skin Av(udil1 9 (h e S Ull takes the 'U n mJi of be'! 119 out doors

T a nn~n 9 preferen ces

~ look bet tel w~,en 1 h,we a Ia n

1 (~~~ hE-a 1 rh~ wh en I "~ve;!l n r r.e ta 11 Tanning preference Irlde>: (2) values ~2

92.S

S7,S

91.8

87.1

89J

916

87.4

84.S

90,4

99.2

814

7'8,9

7'9.9

1 ,0 ( ~ 5.3 [0 r. 3)

-1.2 ~-5]to 3.3]

35,1

'1.7 t -,4.7 to ,f3.ll

95.1

4.1.:1 (J J'i [00-,6)

90.9

3. g~ 10.0 101 'l.8)

19:ii

]] (- 0.4 [0 7.8)

'90.~

73.0

69.3

-4.9(-1 UHo 2.1)

65.0

-8.1) (- '~' 2. -, to -16)

68.8

SB.O

- I O.H! {- '18.4 to - 3.2)

1'7.8

68,0

-9'& (- nlO to -1.6)

7 .J

86.3

3. 5 t~ ([l.S to 6.S,)

87.S

90.2

4.3 ~- LI to 9.6)

84.0

'.3 (-1.1 LO 9.7J

810

913

71,7 4.8

&3.3 SO,O

11,&! (7 5 'to 15,5) S,2f1 (O} to 9.7)

64.6 51.3

g,,2.J 11.7 to 14.6) 8.911 (1.6to lo,n

00,0 2.9

80.0 5 L1

l4,O..l (7'.01020.7) R2n (0.8 'm 15.5)

7lS 51.~

86,S 46.6

12,7',1 (5.0 to 20.4) -~.8 t-13.7 to ~.'I)

71.2 Sltl 56.5

67.8 55.0 S i ~,

-1-4 ~~' 77 'to Cl.9) 1,6 { - 3.1 to 5.3)

- 5J t (-9.510 -O.7~

64 1 48.] 495

{d,S SQ.]

45.6

76} 57,S 53.0

69.0 57.0 52 1

~ 7,7' ( - l 6. I to 0,8) ~ 0.8 [ - 1 Q •• ? to 8.6)

- TO.9' {-"I'9,6 [0 - 2L~l

75.3 56,11 60.2

72.4- 57.0 56,2

- 2.9 (- ~.6 LO 3,,8) 0.0 (-7.1 [08,6' -,4.0 (~i 1.2 to 12)

-23~-9.7to5,l) 2.S (~S.I to lQ,.n - 3.9 (-1'1 I '[0 .3.3~

Ge!lrnIllJe'r RaGe
Boy-s Giirl~, Whib~' INomw1hii~e
11998, ,2!DD4" (tha rngie·1OO4,-...'119-ga,f '199Sj 210'04,- C:hange 2004~· ~ '99B~ '1998'1' 20M'r Cha nge ,:;!C ~4~ 1 gg$, ]'998 ,21004" Ch 2004 1998
Iliangle , •. - .' .. - •.... ,--,.
'" '_~ . -~. ' ~
% % % (195% CI) % 1% %, ('9.5% ell] % 1% %,(95%(n % Ok % (,95%,(1)
Anitudes 011 benefits of sun protection
Pn:nec'[ I 1'19 my ski n r rom t he' 5 u n I s a I) ea.sy 85,6 91.3 S.7'~ (1 J to 10..0) 899 944 ,4511 (0.8 (0 8, 'I ) 87.9 95.3 7.4.1 (~. 5 to 1 O.2) 86..7 B4J ~2/1, (- '10.5 05.7)
way 10 May h ea I [I, Y
1I5~F1g sunscreen allows me· [0 enjoy the 80,1 82.2 2.1 ~~2,9to7,n 89,S B7.1 '-,2,0 (-6,1 to 2.1) 8SJ 88.1 .2.8 ( - 0.4- to 6,.0) 82, i 72.7 - 9..4 ( -, 1 as (0 C, 1 )
a utdeors wi'[ h I ess wo~ry
S pe nding ~ [me au [doors wi thou t any su 11 89,6 94.9 5,3LJ (1.6 [08.9) 92,4 953 ,2,9 (-0.4 to 6.2) 92. ~ 9'7.0 4.9'-1 (.2.5 TO 7.2) B6) 89.0 1.8 ( - 4,8 'to 1 O,~~ l
protecnon can increase my dis nCE'5 0.'
dE\lelop~ng c,; neer .
My ikin won"~ wrinkle as f~s' I '1 spend less 63,5 595 -4.0 ('-1 0 . .7 -0 ,2~7) 79.2 70J) -8.& l- 'Pl2 UJ - 2.QI 7418 68.9 -So (- 10.4 to -1.3) 67',0 51] -I S.3~ (-26,5 [0 -17~
....
ume In 'Ihe sun
Sun prcrecnon vndex ('I) ... slues ,<,l 83.0 86.8 1.8 (-0.7 -0 8.3J 89.6 912.8 12 (~'O.5 '07.0) 87.9 93.3 :5_4 ~ (2.7 c 8.1) 79.S 7j.7 - 1.8 (- 1 1.0 10 7 J)
A. '1ltlllJdes on outdoor SilHl exposu~e
l'he ~un 'eels good on My 5kl n 72,6 32.5 1 O~O j (4·.210 ~ 5.7) 70.9 8~tl 112" (75[0 IRS} 71~l.S 861.0 9.5,) (5.5 to Il5l 5~ 7 74 . .0 19.9 (8.8 to 30.9) -

u.! L.A ro

"'0

'-'"

""ID

:3

cr' I"'b

.....

P report ion of Yo u't h 'WIh 0 "Strn n 9 Iy A,g ~,e,@IF or N,Ag ree"

G~r115

White'

'~998r %

Ch a rn·g~· 2004~ 199B~ % (95% CI}

Cha ng,e' 2.004~·] '9918r % (9,5;% CI)

11' OCi.Ci'

. ~'];I'IiJ;~

%

Chanqe 2004-,199Sr % {95% CI}

1998~, 20041

% %

C ba n gie .2004-1998~ % (9'5% (I)

2. 0 Q.4,., %

199a~, 2.o04j

1% %

2t(J(}~'1 %

Avoiding the sun takes the fun out of bei rl9 au tdoors

fain 1"11 ng preference

I look bener w hen I have a Ian

I feel hea It.1Y wh en I ~l ave a nice (an T,annlrlg pH!ferE'nce il1de~(2) values <2

43,0

S}I f2.4 to 15.0)

-2..3 ~-13] to9J)

51.7

46.7

1,6 (-4] to 7.9)

51,0

73.3 70,6 ,-,2.7 r-as [0 3.1) 09.2 65.0 ~~t2 (- t D,S to 2.0) 76,0 73.6 ~ 2.4 (- 6] to 1 ,,9) 53.0 47.8 -52' -16.9 to' 6.5)
57 9 57..2 -0) (-7.310.5,9' 49.0 52.5 .3.5 (~3J to 1 0.1 ) 58,.0 59,0 1.0 ( ~4.0 '[0 6.0) 37.8 40.5 2.7 (- 8.6 to 14.0)
ElLl 53..2 ~ 7.9~ ~ ~ 14.0 to '-1.8) 52.0 49.5 -'2,5 (-8,7 to3.?} 60.7 56} -4,0 ( - 8.010 (},6] 50.5 33A - 17. P {-,27',8 to -·6.4) 19981. 2004'.r

% %

(ha nqe 2004- 1998~ % (9.5% (II,

Chaln-g'l! :2 004-·1 '998.~ % (95% (I)

'1 '998,r 2004/..

% %

C ~ .. . .' "1·lI"I;iI14- "ii 'OlnO

, 1IIIa ng e' "",vv' - II :;.;. ;~r·Q.f

% (95% (I)

11 998r, 2004,

% %

Attltudes on benefits of sun protection

P rorecn n9 my skl n fro m ~he SLI I'll san easy WJY [0 Slay hea I'~ Ily

Usi ng sou nscreen aUows. me to en i O~I " Il€ outdoors with less worry

S pend i ng [f me outdoors wit hout a ny sun protection can ill (; rease my d1 a nee S of develop 1 ngi can r:e r

My skin 'won't wri nkl e a'S fa s t if I spend less time in '[he su n

'S un protection Index {"} va III es ,< 2.

Atnludes Oil OUidOOf sun exposure The SlJI'I1 feels good on my skin

Avo id ing the su n ta kes the hi rl 0 ut of Dei ng outd oors

11 all n r 1'19 prefe ren ce

I look better when I h ave CIJ tift 11

I feel Ilea Ithy when I have a nlce ta n

T a 11m In g preferen ce i nde~ ~ 2) v~ lues ·...::;;:2

8.1-4- 87.0 3.6 (- 3.0 to 10.2) 88,6 95.0 6.4 (.2.7 'to 1 O.O}~ (}'1.2 97.0 5.3 (1.6 ['0 1 O.o.~n
77.5 75.2. -l.J ~ - 9.8 'to 5.2.) 8-6..2 86.9 0.,7 ( - 3.6 10 S.O) 90.S 9.3,i~ L.9 (-·l.9 to 7.7~
85.9 9.2.5 o.6b (0.8 [0 llJ) 9.3.2 95.5 2J (-DB to 5.4) 92LS 98,.2 5.7.1 (l.7 'to 9.6~ 65.5 59.7 ~5J3 (-l4,6to 3.0) 77.0 67.7 =9.31 (-15,1 to - 3.4) 74,7 67.9 ~ 6,8 ( ~ l5. 7lG 2..1 )
77,4- 8.2,4- 5.0 ( - 2.0 to ] 2.0) 39,T 92.1 3.1 (- 0.5 ~Q 6,7) 91] 95,8 4.1 ( ~ OJ. [08.5)
72,2 82.9 10.7.1 t2 .. 8 W 18.5) 73.9 85.3 '11.4.'1 (.5,9 to 16.9) 60.4- S1.0 14,&1 (5.7 to .23.4)
47.4 54.6 71 ~ '-1 j to lS.1) 46,6 4R2 ] .6 ( -'0.1.8 to S ,0) 37.9 48,0 ~O.OIl (1, I to 1 B,,9) 72.2 69 ... 1 -.3..0 t -11,2 to. S,2) 74,6 '?1} -1.9 (-,8.710.2.9) 62.2' 58,2 -4,0 (·_·13.6 to 5-,6)
58.0 56,4- -1.,6 ( ~ 1 05 'to 7.3) 54,5 57' 3 2.8 (- 3.8 '[Q 9)1) 44.5 480 1.5 ( -6.3 '0 13.1)
59.6 53.5 '-6; 1 (-14.5 to 23) SEtS .54,6 - 3.9 (-'10.0 (0.2.3) 485 ·41.8 -6) (-15.0 to 2J) ('llrldl(.me~ percernaqe prevalence score '<2 for benehts of sun pro~ectlon at'ti'tude~1ndE'~ r:::omi5ting of four 11I~m.5: "pro[ectin9J my skill 'from !he sun L~ an e-a)yway to:5tay healthVj" \.lSH19 sunsrrsen allows rneto i;f'ljoy rheoi.H'dQot~ w~~'1i less worry;" "spending 'time' QU.td001~ WjthOL!t allY sun proternon Ciln 1.,,::re8se my C.hilIi ces of~eve'lopirLg cancel,· and "'my ~km won't wllI1k1e,as ast If I spelld less nrne mthe sun', measured on a 4~·polnr Likert scale, rhes~ were 1 ~ strongly agree, 1 ~ agmt\ "3 = dis..agre€r and 4-:;;;::;: 'S.t'forlgly d~sagree (reliabjli;;'~ coeffidenr Cronbach e = ,62). (2~ indi(ates percenraqe prevalence score <2 for tanning appe.al.aU1tudes inde-:-: cons;5.t~ng oflwo lrems ftllook bel er when lhave a tan' and HI feel healthy when I have a nr[iE' tan·; m~a~wed on a .t1-poirll U en scale these were 1 =: strongly tlgf'~eJ .2 = .fI9re€, 3 =- dlsaglee, and 4 = ~uo:ngly Olsagl'f'i!' (r~lmbdi''V coefficient Crortb~ch 0; = .59}'

.l P < JJO L

b1r:J< .05,

protect themselves from the sun, lnade quate application of sunscreen fie', not enough applied or certain areas of The body missed) or sunscreens degraded or washed on': fr0111 swimming, sweating or other actlvltles may unde rmine the SUT1S(ree'H efficacy for prevention '0:[ sunburns. ~,~-;Ul Our f ndlngs showed very Iew improvemen ts

in tre nds for 'the regular (routine] practice of St1 n protectlon behe viers and run anltudtnal prefe rences 1,0 tann 1 ng;., W h e re as. som e ~ ren d s 'i: n ba rri e rs to re d 'U (ted s u n exposure increased, Sperificall y i' between 1. '998. and 2004, the only posltiv ~ increases were for the regular use 0:[ sunscreens .. and there 'was a slight and nonstgnlflcant reduction (.2%,) in the preval ... nee of regular use of sunscreen with SPF 15:'+ when at the bleach or. pool (5,8% VS 5,6%)., Sunscreen USt:.' continues UJ 'be the main for '11 0'[ protection [ro~ll the sun practiced by youth, 0 ur st udy found ID),O changes, and 'the regular use or other 5lU1. protection measu res ,( ie, protective clothing, seeking shade, and wea ring sunglasses l was less prevalent. In particular. the regular use of wide-brimmed hats in this PO].lU](J tion was 'very in .requent, Resea rch is needed to understand the re.aSO,H'S or barriers (eg. attitudes. norms, or contextual settings) related to the' low adoption 0,[ such practices,

Modest but slgnifican l increases in the prevalence ,(iF youths' attltudes related to benefits of sun protertl on OC(U1Ted between ~ 998 and 2004;, 'youth In. general seem 10 hold largely poslti ve auttudes (knowledge- related benefits) toward su u 'protect ion (with the exception that knowledge levels about the effect of 'U"V' exposure and skin photograph -agirig effects were moderate). ~E,J ucational ski W1 <cancer prevention efforts in schools, Uti tdoor aquatic settings, and media campaigns may have contrlbuted '[0 these improvements in att itudes/ knowledge d u ring t, he 6 -year period. l u. l8\; ~,~ ~.n addttic Hi' aJ though

trends showed modest decreases, youths' tanning :J1reJ:'·, erences continued to be prevalent, and barriers related to sun exposure (o'Jsu n feels good on :n1,Y skin' and "avoldlng the S11l1 take'S the fun out of being outdoors") wn("l]~ased du:d,ng th~s pericd, This nla.y sug,gt:st t:ha~: skin can.eer pre'V,t, ntion 'e ~for[s 1 cb.l(j,[l,ge such atU'[udes [n,a y been (s.un~H,:'vvl'lat) 1,f'ss effecHve in" you th (>r ~,hal o(h er fac~ors" such as soc~j,a,:~ nor]]]J,s i[oward tann]ng .. fash](.,n trend.s~ ,P,t'er pressure~, and the lack, of puHcies to sup:p,ort suu=s.a,":,e envlrOlll11.entsr nil.ay h,l),v,e been nl0re iinHuenl..ia,] so as. to :I:frfcltl.de changt:s in att~tu,des. 41 .... H 'Becausle such alIi 1.udif's ar!(!' ,deternli narHS of su n eX'llosure and sun pro= Lection 'beh,avlors~ W,l ~-,IS.lc~-.Jh~, h rns lrnpor~ant 10 IdE"ve]op

beller ed,U(alio:na] nles.sag,f's and srralegie'S 1.. ·r,ge~.ed at YOluh.,

There we re se'vera] s'~rengths and l~Ill wta ~i.on'S i.n th,]!) S':[ udy ~ 1'h r: surveys LI,$t:d the sanlt In.strlu,~llt~nl.S" wh iell :in(-'!ude' ;( uesHnns rur [TI,ultjph::~hth,avior and. ,anh,ude end, po~nts.! a,nd t'h ~ SZHlle p,['-oba'biUly s,anlpli:ng ]]l,ethodnlogy 10 al]o'w' for ,ge;!lr.:ra,1 ]zjng esti..rn,ales to ~ht: elll ~:rt pOp'Ll la =' lio], of U'S ')''0 u tb aged :~:, ,,[, tu ID 8 '~{ea,rs;, li:owevC'.r, the

162, (OK~KIN ~DE ~ e't d I

1[.t:',I, ephon e su rvey rnethodolog Y' limited the generaliza bllity of results to persons with a telephone (----95 % of 'US households) .'I~ Particularly in the 111,OS'[ recent survey, a substantial proportion ot households 'were n01 reached despite III ultlple attempts, 11,r selected sub leers did not complete the telephone interview. a nd. rhus, a potentlal for unmeasured bias may be present. The sampling des[~n allowed for a ret resentative Sa111~1)]e 0' the 'us ~)O']J·'

~ 1 ,W J, [,

'1.1:1 at] on ~ b [I, t certai n low- Ire que ncy pop' ula, t i: 0 n S Ul bg to up S

~ m] . d t " ·lIi'· d

'W'(:~ r,f;' u 0'[ we w rep rese me . ,~ oeca U Sf! co Sl 1 ssues u Ii n O~,

,pe[[11H oversampling. 'W'e note that skln c ancer is higher among the whlte-skinnr d population. a group that is well represented in these surveys. Data used in this study were based on self-reports and possibly subject to recall bias or social deslrability bias. However, surveys were conducted in an anonymous fashion. and 'Q ueslions gathered lnlormation about recent events and experlences occurring tither during the past summer (2-,4 months before the date of lntervlew) or wlrhin the last year.

Internationally t Austral ia h as served as a 111 ode] of a na E i 0 11,21. ~ ( t n scope) co rnpre hensl ve sk ln ca ncer prev e ntlon progran1!., which has used systematic ongoing population-based tracking of disease and behavioral end points, l.t:. so, 5] Earl y in the ~ 9705,1' Australia developed a national health care policy '[hat made skin cancer prevention a public health priorhy: the Australian public ed uca tlonal campaigns known as SHp~ S,~oJJ :!~ S lapt i slip on a shirt .. slop on some sunscreen .. and slap on, a hat) and the SllnS man program, the most recent national program, involved multipronged approaches in variuus settings (schools, worksltes, a nd health, care systems) ~ as well as envlrournental SU'p·. oorts and polides.w In the

,j ~ l

United Stares. several broad-based nattonal, state, and

private ski n cancer primary prevention efforts have been initiated, and most target primarily children lS",~9,$,2-~) In

light of 0 ur flndlngs of. mixed resul IS, 011 sun protection a mong 'U S youth" there Is a need to : 'urthe r expand efforts ~:n: t,a,rgt:t~,:ng youth ,and to l.rnp'fove d1e 'effec'[ iiVt.'· H'f'S.s of l,h,e'se progr.anl.s., In, addiHon to the assess,~nent of ,e" 'k· ~I· ~1·· F'"~ '~]. C'ld;' r cJ ~, S l.:ri ~ 'Ii:' JCi 'ill 're 'I'] Cal c '11' [1 ,p r,;l3 ~ S a· ]1 ~ ~ r!JI ,ro'· "["' .£"0"[1 C ... 1I '·[11 ]"

,j,,,,,.],, "4-'(1.11" :·'Il."...:,l!!l,· II,.,.(;!.;:)' .... Iii. ,,t, ~.;);; !J.,~: 'IL- 'I;... W. ,c; .; iii... 'L 'L.~. ,J.', 'L .. ', .. it.!!', "" ,-

'ii'-~ 11 '-[ C' -l~ i"'ve'"l] l:'"l]n ('i.1· ar'L~'V· mt·,~,r-;,S· ["0 'Ii]l('ii~'''ii ~"I'OC.· ·r' 'C"-l!~"ii''''' '~). iI"'I[)'~' iI'.:Ji,C'·t ~:;('l]1I

L·iEy, " " .' ~.,IJ.". ',", . , ~!~~.:...!~./. I~ . I~ !L'~ til tI,~ ," ,~[., 1Il", ··;!(~"JLILL'·. ";, ~I ·~,IlJj, ,~:'JJ,!Ii' !L,~.::... ,,~v\~J

pra. ctioes, a n, d s,u n,b u rn :ra t e.s J 11 'yo 11 n,g s ~,e-:rs ( and i 11 S II S = cept['b~,e h,]gh,m·tisk I)OpU~alrnolls} J' 'the reby ,~dlo\rving ~:h!e' U]lWt.,ed State's to Uleasu,n: success in. skhl c;;u cer 'pr'~Ve]l=

. " d I . " ., cl'· -b t· d .'

'I: I~'I .\".: '11 '~", I 'I,g,[I'\!' [,' . !":', ,-",1 i ',I'I"I!'I~III-' '.' .. ~ -'.".' ·'';;·-I·.I·:·'';;::-:'L~ .. -,

non !sl[n , 1 ec.ucuon u] .. ]sease . li.lr.c,f"n as ,1,neOl plHate _. Ul

'Ob]ect,~,v'f: 3-.9' of Hl'e" lIe'ahhy' P~op]e ),010 go,cds..'S{~

(,'DiN,CLU5110N'S

,De'spite 110derale i.n,creas'e"s iru., ~,he :regulaJ' use 0:1 su 11 ,~, s(reens ,an1.o.ng 'U'S youth belw'(~en 1998 and 200~~t there 11.a,5 nOl be. n adeq ua le adop'tkln {)f te;;gula ~~ use of other n:'cornnle nded s~J.n 'protection praclrnces,. Moreover; a1-, tbou,gl], tht: diecrleasing trends In SJL],[],bu :rns anlon,g

'! ~'.~ ~I .~ 11]·· (1' Cd> r- ~. {c.l if.-'!' 'i]C!l:' ~i"Yl ':II Y g';' v.r-o (' . ''!;. -"'II'] ,;:;,'i; (' '=iI 11 iC l-"!o f("ii -r- o "1') 'Iii '·1 ilFtlfll'l· e- 11-'1- 'I' U

J·[Ul!L!~,!IJ"'61~.1 ,"~CI~~:;j IL,LI1'-t", : .. ·'~l··IL I.jt.l~.[~l'''\.... '. Ci .. _.;jI~ .l':"J!~,~ : ·t:.lt..,lJJ.~~ I~I~._, ,l~-='

g,ardin,g Iuture trt::nds ]n skin ca.l}()e'r~ 111ere W'Cl:S l.i'ult

ove ra ll '~"'h~ ,r: I.~'t;' :I n S IU. nb u rn n re W ds d u rl n g th is pe nod: t h us, S ui nme r . U n burn s experien ce s am 0,1' ,y yo U ~ III re ~ ]11a,Wn high, The findings suggest that ,CUi rent I~ fforrs :i 1 'n h e 'U', 1 "le d : ts U:S t", ard sk ln . - iU11' er I (ire vemlo 1 have 1].01: been sufftclent to have a J11 jl 'r impact on overs U su n protect ~ on a .nrl o ng Y'o 1.1 t h ~ ~ I,' Th ~J s, th e re ru ~a nee d 1[' ~ strengthen the lmplemematlon ol skin cance - prevennon progrs ms a nd lnterventlons along wlth environmeat al st If U (~ u ra [ S U pport S, and pol rn ',' lie's ~ tJ\o I ~.I iJ.-IlA' 1. hat

nUlY help , 'hape the socia II and ph ysi;(a] 1~'.nV'1.~·[H ment Bind pron ote S,'U'$~,,' i nab~:lli'I.'f 0:[ the e 1'f1og~'c ms, _ 0 stre 19lhen lmplem " 'n ta I[ io n 0 _. ::,1<.1 n I.'\it " n er ~ re .. , e n. ~ lo n, rese ~ "Ir'C~ 1. i 5, needed OIU elf 'ectlve m echa ulsm I[(}I broadly diffuse skin ca. ncer I,' l'e', ~ n '[ ~ on t n It" erve n t ion !a n d sun ... sa e ~ '~1 pol ~ ern es in communitie .. ,';7 and in schno~s~~,,17 and fur ~f ective

ways to increase the rol 01:[ pl!~dja'tdci,a:ns !m nd hea ~Il h I.' a [1< providers \¥:i tb thei I~ patten [:S'!jg a bout sun S",~!~"t,~, practices to n 'i n im rn ze rl sk S a S sedated wl'~ h exc ess lve 'U' r ex P 0:, U re,

AC' '1··0' "'W'ILE: D' "M E~NTS'

, • i I If'll ' , ' ,II: J' I' E: f - 1-::.:.

Data cOn,elrl~on Ior '[he' 119'98 Sun '~··Llr' e'~' ,I was lunded by '~. h e Am - 'r~, ill n Ca _1 cer Sod :"'t y as ~ n i n 'I ra ~ 1 U ra r 'e',a rc

. ) roject, ~,~ Ita "uUe tlon fur 1,:1:1 e 20104 .s u n S. u rve ~~' :~ I: was flna 1 (:ii.a.U ~fl supported by' :,' 'lUJ'nr'ogna orn rarloi .

- - - , I!&

:RIE,f.EIRENCE'S

~.. An1.er:~c~ n CanC'cr Sucie'!. y. Call,,' t PadS Uli:d PigUil/S." .A 1Ia,I'],UL G.A:

A. nIt" r:~,t',a n :, a n(·(~':r S ud,(:! l Y: :2 00 6

2., J'erna I A, 1[J'l'Vt!5iB S" 'Ha,rlt~"t f~ Tucker M,. i~e':'C'JU ul"nds in C;UI[an.;ous; ~n·C'~~lnUJn.l,a. inddt!fu."e ~'1J11JOWiiK r hrn,~cs ~n I~ hL" 'Unim,ed, :S~.a'U;s~ JI '~.rI't Cd",~lrr.l~ IJls,r~ 2.00 ~ ;It)'1:6','S=,I5S3,

3" BO~r e' ~i:" 'i, !,1"g,~ . iP ~ , In,Jn, j\ft em. tid. I\J1'11 ua r,e:purn I~ 0 ru hc' In a'[ ~ou 'n 'I bt ··lla Ii U ~ 00 - ra n ('c'r I( 1 !~'i' 1, [h ruu,yh 1 9'9'.8)~, '('If I U rii n~ c,a U(lers

~~~ii rn h n.:;t"t n rn ru n!l'll~aSrn n,g ~ r,t'l Itls. J r' dll C{"',U"ll~,r .I n~'l. ,100 rn ;"9' 1:

,8,24=8,4·2

it, IChr~'!)II:c'n:"!OIIIIl ''f H"(MfllnWn13,1], T Va,chon C~ t'[ a~" IIIU.·~ltill~ncc' n' I basal ,~n ,i] nd squ,a.l1]ou~ c,eU ICtnircmnon~"as in,', 1]'OllUII,illiu[ yO'ru,~r~~:~'CI~ l_l,iln 4:0 lrc'.ars .. lA, ,~A. 21[) 1]'5:,29 '·:6S·~ -,6!,O

$ .. _"lalri', R .. Gri Ifh t K~hl [lin T'm TIl't:I1(ls iin Ih(:' incildc'nc1C' 0 InUl1J~ ·r.ll!t'la:n:ulrl'lal '~',ki n. · alfllc,e~ jill '~OU~ he'a' ·~t~r_l i\lrh~~).I1~~ :1985- I, '9916 .. J i~J'Jll .I11,',ltJ .D'!!."u'~'dl(Jl, .2{~U:l. ; iii":: '5,2:,8,-),11,6,

o. KaIF,a,Y!i'~ M" G:rc'l~nl'H~~fg Ie .. S.1~cn('cr ')~ "UJ k~'~1 1"j' Muu L, :N]'e'w' f~',a:lupshi,r'l~' SJdn c.~ Ir~li ('r' S:~.II!;Hd'Y G,rnup,. :~.a1[I~C~ ~f' i:11i inCi.d!lcnc[' raJ [es, o'r Ib;f'iJ I '('(:'1'1 iJ nd sq U,iI InoO II s (c'lll s,k i Ul (' ill n{'~ r ~i 1 ~ Nt""\J\f I, 11,i) nl p = $h W fe.. -, ,~"A., IJ"',; .J C U'~'(,~ir~ i 9199 ;',80 ~ : '; 5 ,),-55,9

1. I n ~,eirnil I iio 11 all A,gc'nc~~ rur Itc'sc'rii r "':11 0111 ,ea II 1. ({"r . J\-J~l'I'~a~!lt; ,lj;}" ~n,r t~:rt;·, E",'td:u ,ll i(JII ~ "("a,d~r~y{..'I,I,i£ R'lsks ld' II"n,,(u,l$;~ ,u"~rd ~;h.)/t!l. ,R:,l l,'it.t# ~,,, .. !~:ot }';;" '}tU'W1_, .~Ii",a'll Ie: hU,:rn,aIUoll a~ ,A.S·c:nc~t I,cr ,lRc~II',{ n.h un ({J, ucer:' I 9192

8". Ar:111 S [, r,l nl g 13 I ~<. r! ·c1< t' r A, 1 h t' t' 1 ),i(.l~·n' ~:I[ ~·k~ g " It ~"~ 'U V in d: u,ccd s.k~i n can[CI\ J PhOI'i.n:h In Phol'oin'~JI' B'. 20(l'l ;63,:8~ ~ 8,

9~ WhU:.l~nla 1.1 ';:~ Whi,1~nla n C. Gn.~·t"n /4.,. ChHdhood su n expos-uri, ,iE! s, a ri s,k .f a,l' [,t ~,:r ffU'" rile ~c ~ ~f) In a: a 'y~t t:' 111 ii, L](' f',~'\d,I(.."'W ~)~: c:pidt"'n11 ~ ~ oio,g,k~ S1 u dl'-?s, C .'~.~'f(r c~ Ut ses CJ~J"'r~'jl, 2 00 ~ ,; I; 2 :16 9'-,8 2

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