Developing Healthy Sun Habits for Life: Title and subTitle BreakChallenges and OpportunitiesLifelong Healthy Sun Habits

Over the past several years, an increasing emphasis has been placed on the need for the development of a healthy lifestyle in the pursuit of long-term good health. This generally has included a focus on proper diet and exercise. Indeed, a large amount of media attention has been dedicated to strategies for creating such a lifestyle. Given the potential morbidity and mortality from skin cancer and the strong evidence pointing to excessive sun exposure as a strong risk factor, it is clear that developing good sun protection habits should be an important component of healthy living. But precisely which individuals should be specifically targeted? In which situations? And how is this best accomplished? Three articles in this issue of the Archives contribute to this important discussion with insights into risk stratification. These articles also highlight many of the challenges surrounding the behavioral changes that need to take place for significant public health benefits to be realized.

In the first article, Aalborg et al¹ report a statistically significant difference in nevi counts between tanned and untanned light-skinned white children at ages 6, 7, and 8 years. The difference, however, was not seen in darker-skinned white children, where no relationship between level of tanning and nevi was observed. As the presence of large numbers of acquired melanocytic nevi (whether atypical [dysplastic] or otherwise normal) has been identified as a risk factor for the development of melanoma,² the authors conclude that tanning avoidance should be considered to reduce the number of acquired nevi (and presumably the lifetime risk of developing melanoma as adults) in light-skinned white children.

Although they offer several possible explanations, Aalborg et al¹ acknowledge that the pathogenesis of UV-induced nevi remains largely unknown. They also acknowledge that the lower number of nevi in light-skinned white children without an observable tan may be due to physiological factors such as an inability to tan and develop nevi rather than lack of sun exposure. Based on our current understanding of the mechanism of nevi development, it appears that the presence of numerous nevi may best be regarded as a surrogate marker for UV-induced skin damage and/or a genetic susceptibility to melanoma.

Aalborg et al¹ devote a good portion of their article to distinguishing their study from that of an earlier study by Gallagher et al,³ who found that light-skinned white children with a propensity to burn rather than tan and with numerous or severe sunburns (presumably light-skinned white children) had higher nevi counts than their counterparts without these characteristics. They also found that white children who acquired deeper tans (presumably darker-skinned white children) tended to have fewer nevi than those who did not tan. Contrary to the suggestion of Aalborg et al,¹ this finding does not suggest a protective effect of tanning but rather that those who tan easily are protected from nevi formation, and thus, strategies to reduce melanoma incidence should focus on light-skinned white children who do not tan easily.

Moreover, parental reporting of propensity to burn or tan is most likely based on parental perception of skin phenotype and phototype. Through their reporting, parents were essentially asked to stratify their children along the spectrum of light-skinned and dark-skinned white children described by Aalborg et al.¹ Accordingly, parents of darker-skinned white children were probably more apt to report a greater ability to tan. That being the case, the conclusion by Gallagher et al³ is consistent with the observation by Aalborg et al¹ that darker-skinned white children develop fewer nevi than lighter-skinned white children. Both articles therefore provide useful information to physicians seeking to advise parents by identifying a discrete set of individuals who are likely at relatively higher risk for melanoma later in life and to whom special attention should be given regarding sun protection: light-skinned white children.

These 2 articles raise the possibility of public health interventions in early childhood for the prevention of melanoma. Children, aged 5, 6, and 7 years, unlike their adolescent counterparts, are more apt to be influenced by their parents than their peers or the media. Accordingly, parental education about sun exposure and sun protection habits represents a critical point of intervention. Parents may be familiar with the adage that sun exposure resulting in sunburns before the age of 18 years increases one's lifetime risk of developing melanoma. Fewer parents, however, are probably aware of the direct relationship between vacation sun exposure and nevi development.⁴ An obvious recommendation that emerges from both facts would be the avoidance of intermittent intense UV exposure during beach or ski vacations.

Two additional articles in this issue of the Archives deal with behavioral challenges and, by implication, strategies for skin cancer prevention as persons grow from childhood into adolescence and early adulthood. The articles by Pichon et al⁵ and Stapleton et al⁶ may be best regarded as examining the problem of indoor tanning from the perspectives of “supply” (ie, access to indoor tanning) and “demand” (ie, the intention to engage in indoor tanning).

The article by Pichon et al⁵ examines indoor tanning facility practices regarding access by 15-year-old self-described “fair-skinned” girls in 116 large cities in all 50 US states. The authors found that indoor tanning facilities in states with a youth access law and those with more tanning beds were significantly more likely to require parental consent and accompaniment. They also found that facilities with more beds were significantly less likely to follow the US Food and Drug Administration (FDA) 3-session-per-first-week frequency recommendation. We agree with Pichon et al⁵ that lack of compliance by indoor tanning facilities with the FDA tanning session frequency recommendations highlights the deficiencies of recommendations vs laws. While 22 US states (or parts of states) have some laws that restrict youth access to indoor tanning,⁷ monitoring appears to be variable and enforcement lacking. Moreover, as the authors correctly observe, the large number of adolescent girls engaging in indoor tanning with the consent or accompaniment of their parents suggests that youth access laws are likely to be somewhat disappointing in their intended parental gate-keeping effect. We thus agree with their conclusion that bans on commercial indoor tanning for those younger than 18 years, which is consistent World Health Organization guidelines, would likely have the dual benefit of reducing youth access to tanning and educating parents about the dangers of indoor tanning.

The article by Stapleton et al⁶ examines the relationship between poor body image and indoor tanning use in 155 female undergraduate students. The authors found that young women who view their body as objects to be looked at and evaluated (self-objectification) and who experience feelings of inadequacy compared with an ideal feminine body image (body shame) were more apt to engage in appearance-controlling behaviors such as indoor tanning. The authors do not address the extent to which their study subjects were aware of the increased risk of melanoma associated with the use of tanning beds early in life.⁸ There is also no discussion about the skin phenotype and phototype of the female undergraduates in the study. It may nonetheless be reasonable to assume that at least some of those students were light-skinned white women and thus potentially engaging in behavior that would put them at risk for the development of melanoma. Much like the case with tobacco smoking, knowledge alone of the risk associated with a distant harm is unlikely to have an impact on changing behaviors perceived as having an immediate benefit. Accordingly, we agree with the authors' conclusions that central to any skin cancer interventions targeting this population must be the message to resist cultural and media pressures and to increase body satisfaction and self-esteem, much like interventions directed at eating disorders.

We make 1 final comment about tanning industry legislation as a public health intervention. It is notable that commercial tanning is a $5 billion dollar a year industry that employs approximately 160 000 people.⁹ Any law banning indoor tanning among minors is certain to be met with significant resistance from this well-organized industry. Adolescents and young adults likely account for a considerable portion of indoor tanning facilities' revenue. Therefore, any law restricting, let alone prohibiting, minor access would likely be regarded as “bad for business.” Until there is broad-based support for such measures, appearance-based public health efforts may more readily motivate behavioral change. A long-term goal would be to reverse the societal perception of tan skin as healthy and attractive. In the short term, media marketing should highlight the effect of indoor tanning on photoaging and perhaps even endorse healthier alternatives such as artificial tanning. Sunless tanning (eg, over-the-counter dihydroxyacetone-based products and spray-on tanning) would provide the immediate gratification sought by adolescents and young adults and may also decrease the use of UV tanning beds, as suggested by 1 study.¹⁰ Moreover, encouraging artificial tanning rather than UV exposure may provide the commercial tanning industry with an avenue for generating revenue with fewer long-term public health ramifications.

The 3 articles in this issue of the Archives suggest that (1) a subset of white children, namely those who are fair skinned, should avoid tanning; (2) adolescent girls have access to indoor tanning facilities despite current recommendations and laws; and (3) young women who view their bodies critically are more likely to engage in indoor tanning. Different strategies for skin cancer prevention are required for the different stages of childhood, adolescence, and young adulthood. The message must be directed at a cross-section of the targeted population, their parents, and our society at large. The targeted audience must be empowered not only with accurate information to make educated decisions but also the right motivations to effectuate a positive behavioral change. Guidelines must be understandable and reasonable so as to achieve a high degree of adherence. Studies such as those in this month's Archives show that dermatologists are uniquely positioned to influence the national discourse on public health strategies to reduce melanoma.

Correspondence: Dr Werchniak, Department of Dermatology, Brigham & Women's Hospital, Brigham Dermatology Associates, 221 Longwood Ave, Boston, MA 02115 (werchniak@comcast.net).

Financial Disclosure: None reported.