The Public Health Interventions Advisory Committee (PHIAC) took account of a number of factors and issues when developing the recommendations.
3.1 PHIAC noted that exposure to the sun has a number of benefits. For example, it gives people an increased sense of wellbeing, allows them to synthesise vitamin D and provides opportunities for physical activity.
3.2 PHIAC considered the potentially adverse effects of encouraging people to reduce their exposure to the sun. These include:
a reduction in physical activity levels
an increase in the prevalence of vitamin D deficiency.
PHIAC believes that a balance can be struck by designing and using appropriately tailored messages – and by ensuring that protective measures also outline the benefits of sun exposure. (For example, by encouraging physical activity when promoting the use of shade or other preventive measures.)
3.3 The majority of studies identified in the evidence reviews were based in countries where the climate is very different to that experienced in the UK (for example, Australia and the USA).
3.4 In general, multi‑component public health interventions are often considered to be effective and cost effective. (They combine a number of strategies such as information provision alongside the provision of other resources and activities.) However, the evidence on multi‑component interventions to prevent skin cancer was weak. None of the identified studies were UK‑based. In addition, most of them focused mainly on the provision of information, with only a small component of each intervention devoted to resource provision (such as hats or sunscreen samples). The majority did not assess the effect of individual components and many of those measuring behaviour change relied on self‑reporting. In addition, the economic modelling found that none of them were cost effective. This was primarily because of the small number of malignant melanoma deaths that they prevented (while the incidence of melanoma has increased in the UK from 6.3 per 100,000 in 1986 to 14.9 per 100,000 in 2007, the death rates are relatively low compared to those caused by many other cancers in the UK). Consequently, PHIAC did not recommend any of the multi‑component interventions that were assessed.
3.5 A wide range of studies in a variety of settings found that information provision (including for example, one‑to‑one and group‑based verbal advice) has a positive, short‑term effect on people's knowledge and attitudes. A small number of studies showed that national mass‑media campaigns can help raise awareness of the risks of ultraviolet (UV) exposure. They can also have a positive impact on knowledge, attitudes, behavioural intentions and actual behaviour in the short term.
3.6 National mass‑media campaigns and local activities to provide skin cancer prevention information need to be low cost to be cost effective. This is due to the:
small effects associated with the interventions
high costs of the interventions assessed
small, quality‑adjusted life year (QALY) gain associated with prevented cases of non‑melanoma skin cancer
small number of avoided cases of malignant melanoma.
For example, a mass‑media campaign would need to achieve a 2% change in behaviour (over 5 years) and cost less than 0.5 pence per person per annum to be cost effective. Other forms of information (such as an information booklet) would need to cost less than £2 per person. (Note: the economic analysis suggested that if interventions involving information provision or a mass‑media campaign reduce physical activity levels, then they will not be so cost effective).
3.7 There is limited evidence to suggest that media images can influence young people. However, PHIAC considered that it would be a positive step if young people's role models could reinforce skin cancer prevention messages.
3.8 The way messages are worded – and the medium used – are important. Parents, carers, teachers and those who have experienced skin cancer could help to get positive messages across.
3.9 Many of the studies involved children and young people and PHIAC was aware that it is important to consider their cognitive ability when delivering information‑related interventions. The evidence suggests that, generally, children under 7 are unable to remember information they have been given previously (even when prompted), whereas from age 7 onwards they can.
3.10 PHIAC recognised the important role that employers and managers in schools, leisure facilities and other workplaces can play in helping to raise awareness of the dangers of skin cancer. This can be achieved by developing policies which cover skin cancer prevention.
3.11 PHIAC identified a number of barriers to providing sun protection which are specific to the educational sector. For example, there is a lack of clarity about who is responsible for ensuring children use sun protection cream and clothes – parents or teachers? There are also liability concerns if a child is sunburnt or has an allergic reaction to sunscreen products. Time constraints and difficulties in rescheduling outdoor activities to different times of the day – or moving them to areas of shade – were also identified as potential barriers.
3.12 A small number of studies were identified on the effect of providing additional structures to create shade in school grounds. The studies found that these structures were used by children and that they may help reduce their UV exposure. Adding shade structures to the existing built environment was not cost effective. However, if the provision of shade was incorporated into the design and construction of buildings from the outset, then it was a cost‑effective option.
3.13 PHIAC noted that the current systems for registering and monitoring national and local skin cancer incidence and prevalence are not comprehensive. (This is particularly true in relation to non‑melanoma.) Consequently, it was not possible to establish the true incidence of basal cell and squamous cell carcinomas – or the demographic features of people who get these skin cancers (such as their occupation group).
3.14 PHIAC noted the risks associated with sunbed use and over‑exposure to UV or burning. It also noted that the Sunbeds (Regulation) Act 2010 makes it illegal for tanning salons to allow under‑18s to use them.
3.15 PHIAC noted that organisations in the private sector, for example, sun product manufacturers, could play an important role in helping raise awareness and providing advice on protecting the skin against UV damage.
3.16 PHIAC noted that it was important for all organisations involved in skin cancer prevention to use consistent terms and messages to help communicate the key messages.
3.17 In view of the economic analysis, PHIAC did not recommend further research into interventions already covered by evidence review 4 (see page 72). If, however, there is a substantive change in the current trends and epidemiology of skin cancer in the UK, particularly in terms of related mortality, then these interventions would be worthy of further investigation.