Even though half of the respondents followed advice to wear SPF 15+ sunscreen, very few complied with all of the advice that maximizes sunscreen’s efficacy (i.e., apply it before going outdoors and reapply it). Advice to use sunscreen with SPF 15+ has been conveyed through commercial advertising and in public health messages and seems to have been taken to heart by at least half of the winter sports enthusiasts surveyed.
Communication regarding pre-application and reapplication needs to be stressed in future campaigns. The effectiveness of sunscreen, particularly those that are not waterproof or water resistant and bind well with the skin, can degrade over time and result in very little photoprotection.12, 17, 18
Unfortunately, too, many adults under-apply sunscreen15
so reapplication is important to correct this, especially within 30 minutes of initial application.12
Failure to pre-apply and reapply sunscreen means that many of the respondents in this survey may have risked sunburns when spending the entire day outdoors.16, 32
The prevalence of SPF 15+ sunscreen use in this sample was higher than that recorded in general population surveys. Other research has found similar elevated use during recreation and activities that involve prolonged periods of sun exposure (e.g., beachgoing, golfing, gardening).33, 34
Individuals may use sunscreen to prolong the time that it takes to become sunburned when intentionally engaged in sun exposure,9, 19, 34-37
including outdoor recreation. However, sun exposure is incidental in many recreational pursuits, and length of sun exposure is determined by factors other than an intentional desire to obtain a tan. Thus, sunscreen use during such recreation may not prolong time in the sun and instead be a photoprotection strategy that actually reduces overall UV exposure. Also, the sun exposure achieved during recreation should be balanced against its physical and mental benefits.
It was encouraging that nearly 3 in 4 adults who used sunscreen had applied it to the skin at least 30 minutes prior to going outdoors. Compliance with pre-application advice also was far higher in this study than in a study of sunscreen use by Lebanese adolescents at beaches.38
Still, many respondents did not report reapplying sunscreen. Low rates of reapplication were seen in another study (20%-30% depending on the body location).15
The lower compliance with sunscreen advice by males is consistent with their infrequent sun protection behaviors of all type (an exception being hats used by men).15, 19, 33, 34, 38
The lower compliance with sunscreen advice during inclement weather and by adults with less sun sensitive skin, seen elsewhere,15, 33
may indicate that some adults are judging whether to use sunscreen based on environmental or personal cues to their risk.
Implications for Skin Cancer Prevention
The next generation of sun safety promotions needs to move beyond simply recommending the use of sunscreen and to teaching adults how to maximize its effectiveness through pre-application and reapplication. There are several benefits from stressing reapplication. It can help to overcome consumers’ reluctance to initially apply the large amount of sunscreen needed to obtain its full benefit (perhaps because it feels greasy and leaves a film on the skin39
). Those who reapply can substantially improve the effectiveness of an initial application of sunscreen.12
Also, stressing reapplication introduces some novelty in the sun safety messages compared to repeating the simple and oft heard message to use sunscreen. Granted, reapplication may not have been necessary in mid-winter (January) or on cloudy days in the winter, when UV radiation levels were low40
in this study, but we found that UV radiation levels measured during “spring skiing” (March and April) at the participating ski areas can be very high.41
In addition, sun protection promotions should stress the use of other forms of protection such as clothing and reducing overall time in the sun, as well as the use of sunscreen, to help achieve a beneficial balance. Decisions to wear head, ear, face, and neck covering in the winter may be done so for warmth protection, which may explain why they did not associate with sunscreen compliance.
The results also indicate that certain subgroups should be high-priority populations for sunscreen promotion. Men may be less concerned with the appearance and health of their skin, and may consider the use of skin lotions such as sunscreen to be less normative than females. They also may not be as anxious about skin cancer as women. Adults who believe that skin cancer is not an important health concern complied less with sunscreen advice.
Finally, redoubled efforts are needed to teach adults how environmental features affect UV radiation levels.42
Inclement weather (i.e., cloud cover) reduces UV radiation only partially especially when UV radiation levels are high in spring and summer, so depending on inclement weather for sun protection decisions can result in risky sun exposure. Moreover, the high elevation and high reflectivity of the snow surface at ski areas increased UV radiation23-26
and adults should consider taking precautions even in winter months.
Strengths and Weaknesses of the Study
There are several strengths and limitations to this analysis of sunscreen compliance. The large sample provided substantial statistical power and the 28 ski areas in nine states/provinces and two countries increased the potential generalizability of the findings. While ski areas were located only in Western North America, respondents lived in all part of North America and in countries outside the United States and Canada. Still, the analysis is most applicable to outdoor recreation enthusiasts that are male and of high socio-economic status. The sample was almost entirely non-Hispanic white but this is the highest risk population for skin cancer.43
The results apply most to winter recreation, a time when UV radiation levels are low (although it UV can be high and sufficient to sunburn21, 44
) and large portions of the skin are covered. Vitamin D levels can drop in the winter, raising concern about recommending sun protection. However, several studies on sunscreen use in practice (rather than in controlled clinical measurement) found little evidence of reduced vitamin D levels.45-49
Dietary supplementation may be the best way to maintain vitamin D levels in winter.50, 51
Another strength is that participants were asked to recall use of sunscreen on the day of the interview rather than at some time in the past which should have reduced memory errors. Still, these were self-reports and subject to social desirability biases and demand effects. Also, the measure did not determine whether adults selected the SPF in their sunscreen by choice or availability (few low SPF sunscreen are available). Fortunately, measures of other sun protection behaviors were obtained through observation which is less subject to recall errors and such biases. A final limitation is the age of the data, collected nearly a decade ago. Since then, information on the health benefits of vitamin D and concerns about the quality of, and chemical in, sunscreens have been in the news, which may have reduced adults’ compliance with sunscreen advice.
The results suggest several additional avenues of inquiry. This analysis of compliance with sunscreen advice needs to be replicated with adults in summertime settings and with children and adolescents. The inclement weather during winter requires more clothing and this may explain why so many adults applied sunscreen before going outdoors.40
Frequent compliance with pre-application advice may not occur in summer where it is easier to apply outdoors when more skin is exposed. It would be useful to determine whether these compliance patterns occur in other outdoor venues and during other outdoor activities, or among a broader sample of at-risk adults who are perhaps older and less interested in physical recreation, or live outside North America. Similarly, it would be instructive to determine which forms of sun protection promotion achieves complete compliance with sunscreen advice, e.g., public health campaigns, advice from clinicians, or social pressure from family and friends. These results should be compared to locations where promotions have been more intensive such as Australia to see whether complete compliance can be elevated. Finally, the association of sunscreen lip balm use with complete compliance needs further exploration. It may be that these products are frequently recommended together and considered by many adults to be part of the general sunscreen advice. Alternatively, the concomitant use of these two products, along with hats with a brim, indicated that there is a group of highly sun safe individuals who have internalized the entire sun protection protocol. If so, they should be described and the means by which their full was achieved investigated to provide insights into effective sun protection promotions.
- Adults should wear sunscreen with sun protection factor (SPF) of 15+, apply it before going outside, and reapply it after two hours.
- Half (49.8%) of adult skiers and snowboarders interviewed at North American ski areas complied with advice to wear sunscreen with SPF 15+ and 73.2% of sunscreen wearers applied it before going outside. Only 20.4% reapplied sunscreen. Almost no one (4.4%) followed the advice completely.
- Adults need to be convinced to follow sunscreen advice.