Guidance
1 Recommendations
1 Recommendations
In February 2016, recommendations 1 to 5 were updated and replaced by NICE's guideline on sunlight exposure: risks and benefits.
The guidance complements, but does not replace, NICE guidance on detecting and treating skin cancer.
Introduction
This is NICE's formal guidance on skin cancer: prevention using public information, sun protection resources and changes to the environment. When writing the recommendations, the Public Health Interventions Advisory Committee (PHIAC; see appendix A) considered the evidence reviews, expert papers, economic analysis and comments from stakeholders and experts. Full details are available online.
The evidence statements underpinning the recommendations are listed in appendix C.
PHIAC considers that the recommended measures are cost effective.
For the research recommendations and gaps in research, see section 4 and appendix D respectively.
What the guidance covers
The recommendations focus on preventing the first occurrence (primary prevention) of skin cancer attributable to overexposure to natural and artificial ultraviolet (UV). Unless otherwise stated, the term 'skin cancer' encompasses non‑melanoma (basal cell and squamous cell carcinoma) and malignant melanoma.
The recommendations aim to raise and maintain awareness – and increase knowledge – of the risks of UV exposure, influence attitudes and prompt behaviour change. They focus on the following:
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Delivery of national mass‑media campaigns and local information provision (including verbal advice and printed and visual material) (recommendation 1).
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How to develop and evaluate information campaigns and interventions (recommendation 2).
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The factual content of information (recommendation 3).
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The tone of messages and how to tailor them for specific audiences (recommendation 4).
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The workplace, to help reinforce recommendations 1 and 2, in particular, to protect children, young people and outdoor workers (recommendation 5).
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Provision of shade as part of the design of new buildings (recommendation 6).
What the guidance does not cover
There are no recommendations on the following interventions as they were found not to be cost effective:
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specific multi‑component interventions (for example, combining information with resources such as hats or sunscreen)
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the addition of shade structures to existing buildings.
In addition, there are no recommendations on the use of non‑information related resources alone (such as protective clothing or sunscreen). The absence of recommendations in this area is a result of a lack of evidence (no studies were identified). It should not be taken as a judgement on whether or not such interventions are effective and cost effective.
The following interventions were excluded as they were not part of the remit for this guidance:
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Policy, fiscal or legislative actions (such as banning unsupervised or coin‑operated sunbed facilities or reducing VAT on sunscreen products).
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Clinical diagnosis and the detection, treatment and management of skin cancer alongside activities to prevent its re‑occurrence.
Factors to consider when planning and delivering the recommended activities
Exposure to the sun has a number of benefits. For example, it increases people's sense of wellbeing, allows them to synthesise vitamin D and provides opportunities for physical activity.
Vitamin D
Vitamin D is essential for bone health and there is ongoing research to assess other positive health benefits. Although the optimum level of vitamin D is subject to debate, it is accepted that a plasma level below 25 nanomoles/litre increases the risk of rickets and osteomalacia. Several population groups in the UK face this risk. (Ruston D, Hoare J, Henderson L, et al. [2004] The national diet and nutrition survey: adults aged 19–64 years. Volume 4: nutritional status [anthropometry and blood analytes], blood pressure and physical activity. London: The Stationery Office; Hypponen E, Power C [2007] Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors. American Journal of Clinical Nutrition 84: 18–28.)
The sun is the predominant source of vitamin D. However, it is difficult to determine how much sunlight is needed to produce a given level, as the length of time needed to synthesise vitamin D depends upon several factors. These include skin type, the amount of skin exposed, the time of day and year and how far someone is from the equator.
Ultimately, a balance needs to be struck to attain an adequate vitamin D status without increasing the risk of skin cancer. (Further information on vitamin D can be obtained from the Department of Health or the Food Standards Agency.)
Physical activity
Regular physical activity is key to a healthy lifestyle. It can help reduce the risk of developing chronic diseases and improves people's overall physical and mental wellbeing. Skin cancer prevention activities may inadvertently reduce physical activity levels as people aim to avoid exposure to the sun. It is important that prevention activities do not discourage outdoor physical activity but, rather, encourage people to use sensible skin protection.
Behaviour change
The principles outlined in NICE's guideline on behaviour change: general approaches were used as the basis for making recommendations on how to change people's health‑related behaviours. That guidance highlights the need for careful planning that takes into account the local and national context and the needs of the target community. It advises building upon the existing skills and resources within a community, and ensuring practitioners have the necessary competencies and skills to support behaviour change. The guidance also recommends evaluating interventions and programmes thoroughly.
Whose health will benefit?
This guidance does not exclude anybody. However, some groups are more likely to benefit (for example, outdoor workers, those who are immune‑suppressed, children and young people and those who use sunbeds).
Recommendations 1 to 5
These recommendations have been replaced by NICE's guideline on sunlight exposure: risks and benefits.
Recommendation 6 Providing shade
What action should they take?
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When designing and constructing new buildings, consider providing areas of shade created either artificially or naturally (for example, by trees).
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When developing or redeveloping communal outdoor areas, check whether it is feasible to provide areas of shade. Shade could be created by constructing a specific structure or by planting trees.
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For all new developments, ensure there is adequate access to areas of shade for people with a disability.