EHJ June 2005, pages 8-10

Last week was sun awareness week, a national initiative aimed at stemming a worrying rise in the UK's skin cancer rates. Stuart Spear looks at what can be done to tackle this new public health threat

The statistics look stark. Potentially fatal malignant melanomas have been the fastest growing form of cancer in the UK over the last 10 years. There are 65,000 new skin cancer cases per annum, although the true figure is probably double this, and 2,000 people die unnecessarily each year.

Yet despite these figures, both central and local government are failing to have an impact on our behaviour. We are still flinging ourselves out in the sun at every opportunity, outdoor workers are more likely to develop skin cancer and, most worryingly, rates of potentially fatal forms of skin cancer are on the increase among teenagers.

At the heart of the problem appears to be a mass delusion, skin cancer cannot be a problem in this country. After all, this is Britain, famed for its cloud cover and disappointing summers. Also, the beauty and travel industries are tough competitors when it comes to getting the message over that tanning can be potentially fatal. Tans are seen as sexy, healthy, sophisticated and are totems of exotic travel, especially among the young. A far cry from Australia where tanning is increasingly being seen as a mug's game.

But it is not just the sun that's responsible for rising skin cancer rates. Our penchant for visiting tanning salons is also part of the problem, especially as many of them appear to be operating with scant regard for the health and safety of their customers. Only 25 per cent of salons are members of the Sunbed Association, which does have a strict code based on Health and Safety Executive regulations. There is also growing evidence that tanning booths are particularly popular in low-income areas where an annual holiday is often no more than a dream. Skin cancer is set to soon become a health inequality issue.

What is clear is that in the plethora of public health roles foisted on local government, skin cancer has slipped under the radar. Some councils are notable exceptions, but CIEH research reveals that three quarters of local authorities do not have skin cancer prevention policies in place, while over half of councils are still offering tanning booths in their leisure facilities. In a bid to redress this, the CIEH launched its Save our skins toolkit, at its skin cancer conference in Cardiff two weeks ago. The toolkit acts as a total support package for councils wishing to draft their own prevention policy to address rising skin cancer rates (see information box 2).

The major cause of skin cancer is over exposure to ultra-violet radiation from the sun or sunbeds. There are two types of skin cancer: malignant melanoma (left), this can be fatal and may occur in the young. It accounts for less than one-in-ten cases. It is often fast growing and can spread to other body parts such as the lymph nodes. Early detection is key to successful treatment. Non-melanoma accounts for nine-out-of-ten cases and are almost always curable. They normally result from sun exposure and are typically found on the face and neck, scalp and hands. The most common non-melanoma cancers are: Basal cell carcinoma - the most easily treated - and Squamous cell carcinoma - more dangerous as it can spread if untreated.

But it is not just local government that has failed to respond to the problem. In 1992, the Department of Health's policy document The health of the nation, boldly declared the government's intent to "halt the year-on-year increase in the incidence of skin cancer by 2005." Dr Julia Verne, chair of the government's development group producing skin cancer guidance and director of the cancer intelligence service at the South West Public Health Observatory, believes that little has actually been done to achieve this. "It is quite apparent if you look at any of the graphs that the incidence is continuing to increase," said Dr Verne, speaking at the CIEH conference. "Very little effort has been put in nationally to raise awareness when you compare resources spent on other aspects of public health."

One group that is trying to raise awareness is SunSmart, run by Cancer Research UK and funded mainly by UK health departments. The campaign was launched in 2003 and supersedes the Sun Know How national campaign run by the former Health Development Agency. In its first year it focused on parents and carers. This year it is aimed at young adults and next year it will be men and outdoor workers, specifically looking at early detection.

According to Jo Viner Smith, campaign manager for SunSmart, the two most important messages in skin cancer prevention are reducing sun exposure and early detection. Young children are key targets for this message as intense sun exposure or sunburn in childhood increases the risk of developing skin cancer later on in life. "One of the best ways to educate people is to talk about the UV index, which helps people to understand when it is most important for them to be inside," explains Ms Viner Smith. The index was developed by the World Health Organization and is a simple measure of the intensity of the sun's ultraviolet rays. Six sites around the UK measure UV and the index, on a scale of one-to-10, is included in weather forecasts during summer months.

According to Dr Verne, preventing skin cancer goes far deeper than just awareness raising. She is concerned that even understanding the epidemiology of skin cancer is posing a major challenge, to the point where there aren't even any reliable figures on how many new cases are presented each year. "Because of the history of the registration process nationally we don't know how many non-melanoma skin cancers there are," points out Dr Verne. "National figures estimate 65,000 skin cancer cases per year, but it is probably nearer 120,00 a year. Actually we don't know and as for pre cancerous legions they are extremely common in the population over 60."

This poses a problem. If we don't know how many new skin cancer cases there are a year, then how are we to know which public health interventions work and which don't? In 2002 the Health Development Agency announced that by focusing on suntan lotions the cancer prevention message was being diluted. People use suncreams to increase their time in the sun. They also fail to properly apply creams, leave parts of their bodies exposed and don't apply enough or with enough frequency. The new message is to reduce your total sun exposure. "There is no evidence sun lotions are protecting people against the ageing process or against developing skin cancer long term," warns Dr Verne.

A local initiative which is attempting to address the issue of shade is the Sefton Living shade project. Cathy Warlow of South Sefton PCT explains: "This intervention is around children, young people and their carers. The aim is to provide shelter and structures that give shade for children where they learn and play by having seating in the shade and creating living willow structures through tree planting." Funded by the Merseyside Health Action Zone, the project also aims to teach basic willow weaving skills to local people, contributing to environmental sustainability standards and local eco-programmes.

Tourist resorts are starting to launch their own local initiatives as cancer prevention is increasingly seen as part of their role to ensure visitors' holiday safely. The Isle of Anglesey attracts 1.5m tourists a year, over a third visiting the Welsh resorts' five blue flag beaches. So it was here that the Isle of Anglesey CC focused its Beat the burn campaign by using beach wardens to deliver the safe sun message, using leaflets, posters and free samples of sunscreen. Similarly, Blackpool launched its own Shun the sun campaign two years ago focusing on the use of shade, protective clothing and sunscreens. Gosport DC holds an annual beach safety road show on two of its main beaches.

But it's not just the resorts that are taking action. EHPs at Bradford MDC decided to address the other potential source of skin cancer, poorly-operated tanning booths. The first problem faced by Nigel Coates, EHO at Bradford DC, was actually finding where the tanning machines were. Companies often run profit-sharing schemes placing booths in small businesses "You will find them hidden away all over the place, a nail studio might put one in the back room," explained Mr Coates. In one instance a booth was found in a cheque cashing business. By working with the suppliers he was able to track down 120 tanning establishments, which were visited. Staff knowledge was assessed, guidance on sunbed safety was handed out and standards in terms of safety information given to clients, record keeping and equipment safety were raised. The project received a highly commended award in the 2004 Hela innovation awards. Other local authorities who have targeted suntanning establishments include Chichester DC, Leeds DC, Bolton MDC and Redcar & Cleveland DC.

Evidence suggests that community-based interventions to promote public awareness and reduce risk can be effective. But trying to achieve long-term behavioural change is a harder nut to crack. One idea which seems to be gaining currency in the Department of Health is the use of social marketing to change our attitude to the sun. A relatively new concept in this country, it is a tool which has been used effectively in the US, Australia and eastern Europe. Historically, governments have used education to change behaviour. Rather than using expert advice, social marketing focuses much more on the desires of the groups whose behaviour needs to be modified. It is defined as "the use of marketing principles and techniques to influence the target audience to voluntarily accept, reject, modify or abandon a behaviour for the benefit of individual, group or society as a whole."

Prof Ken Peattie, director of the centre for business relationships at Cardiff University, is a strong advocate of social marketing and has been researching the skin cancer issue. "The value of it comes in applying those commercial market techniques that we know are powerful to social issues and social causes," explains Prof Peattie. "If you look at the sunbathing skin cancer research it shows that raising awareness does not lead to better more protective behaviour."

His research looked at the obstacles preventing the skin safety message getting through in Australia and the UK. Again, he found high levels of awareness about the danger of sun exposure, even among six-year-olds in the UK, but this was failing to change behaviour. "We found that the problem was not awareness but how people lived their lives, time pressure and other competing problems stopped them being sun safe and one of the things marketers have become very good at in commercial terms is understanding people's lifestyle and making a product fit into people's lifestyle."

The sorts of obstacles his research threw up included a fear among UK teachers of helping children apply suncreams because of possible child abuse accusations, along with a tendency for parents to stop being concerned about their children burning after they reached 11. "It is a magic watershed where children are left to their own devices," said Prof Beattie.

Looking at both UK and Australian government policies reveals a worrying lack of consistency over sun safety. Bus stops are often in the sunniest spots, forcing children out of the shade, governments tax sun screens, sports days are held during the hottest part of the day, and so on. Prof Beattie believes that the merit of social marketing is that it "looks at different types of people and asks what stops this group from joining and it seeks to identify barriers".

One area that requires more research is outdoor workers. The HSE considers UVR to be an occupational hazard with outdoor workers more likely to be male and from lower socio-economic groups. A recent study by Cancer UK found that it was men from this group who were likely to be least informed about skin cancer and least likely to wear suncream. The HSE has published skin cancer prevention leaflets but there are few long-term conclusive studies on effective work-based interventions.

Despite this lack of evidence, work still needs to be carried out to raise employer and employee awareness, while periodically ensuring whether workplaces are implementing effective skin cancer strategies. Not doing anything about stemming skin cancer rates is not an option. "Current trends show a trebling in the incidence of melanoma rates over the next 30 years unless we do something now," warns Ms Viner Smith. "Even if we start preventative action now it will still double in the next 30 years, because of damage we have done in the past."

Sunsmart website: www.cancerresearchuk.org/sunsmart/staysafe/

SE guidance on sunbeds; www.hse.gov.uk/pubns/indg209.pdf

Sefton Living shade project: www.livingshadeinsefton.co.uk