Preventing Skin Cancer: Interventions in Outdoor Recreational and Tourism Settings
Task Force Finding
The Community Preventive Services Task Force recommends interventions in outdoor recreational and tourism settings that include skin cancer prevention messages or educational activities for visitors, and may also provide free sunscreen of SPF 15 or greater. This recommendation is based on strong evidence of effectiveness for increasing sunscreen use and avoidance of sun exposure, and decreasing incidence of sunburns.
Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.
Interventions to promote sun-protective behaviors among visitors to outdoor recreational and tourism settings include at least one of the following:
- Educational approaches (e.g., providing informational messages about sun protection to visitors through instruction, small media such as posters or brochures, or both)
- Activities designed to influence knowledge, attitudes, or behavior of visitors (e.g., modeling or demonstrating behaviors)
- Environmental approaches to encourage sun protection (e.g., providing sunscreen or shade)
- Policies to support sun protection practices (e.g., requiring sun protective clothing).
These interventions may be directed at adults, children, or both. They may also have components directed at improving sun protection behavior among employees.
Visitors to outdoor recreational and tourism settings may have an increased risk of excessive UV radiation exposure for several reasons, including:
- Spending an extensive amount of time outdoors
- Unfamiliarity with the settings, which may have high UV radiation intensity due to factors such latitude, altitude, and light reflective surfaces (e.g., water, sand, snow)
- Desire among vacationers to be carefree
Operators of outdoor recreational and tourist facilities can play an important role in helping to address the heightened risk of sunburns and ultimately skin cancer due to these factors by ensuring that visitors are aware of the risks and are able to effectively mitigate them.
About the Systematic Review
This Task Force finding is based on evidence from a Community Guide systematic review published in 2004 (Saraiya et al., 9 studies on behavioral outcomes; search period January 1966–June 2000) combined with more recent evidence (8 studies, search period June 2000–April 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing skin cancer. This finding updates and replaces the 2002 Task Force finding on Educational and Policy Approaches in Outdoor Recreational Settings.
The following results are primarily based on evidence from the updated search period. Included studies (8 studies and 13 study arms) assessed intervention effects on various measures of sun protection and physiological outcomes of UV radiation exposure.
- Sunscreen use
- Included studies found the intervention increased sunscreen use (5 studies with 8 study arms)
- Sunscreen use increased 12 percentage points for children and 9.1 percentage points for adults (1 study)
- Amateur golfers used sunscreen an average of 1.13 more days per week when it was made readily available in locker rooms (1 study). During competitions, athletes increased reapplication of sunscreen by 22 percentage points (95% CI: 0.9, 43.1), though reapplication during practice did not change.
- Children enrolled in ski and snowboard classes at high altitude resorts and their parents increased sunscreen use an estimated 20.0 percentage points (95% CI:10.1, 29.9) and lip balm use a non-significant 4.0 percentage points (95% CI: ‑6.2, 14.2).
- Remaining studies used various measures of sunscreen use and showed similar increases in use, particularly during activities other than intentional sunbathing.
- Included studies found the intervention increased sunscreen use (5 studies with 8 study arms)
- Sun protective behaviors
- Results were generally favorable for other sun protective behaviors, such as use of sunglasses or ski goggles (1 study), avoidance of sun exposure (4 studies, 8 study arms), and combined sun protective behaviors (3 studies, 5 study arms).
- Physiological outcomes
- Two months following an intervention focused on educating beach goers about the effects of excessive UV exposure on appearance, a small and non-significant decrease in skin darkening due to UV exposure was seen among participants (1 study with 3 study arms).
- Sunburns decreased following interventions in two studies.
- A non-significant decrease in number of red and painful sunburns was found among female beach goers in intervention group (p=0.8).
- The proportion of tourists presenting with at least one sunburn during their stay at a beach resort decreased among both an intervention group that received free sunscreen (‑16.9 percentage points; 95% CI: ‑28.9, ‑4.9), and one that received free sunscreen and information on sun protection (‑25.6 percentage points; 95% CI: ‑36.9, ‑14.2)
- Of the eight included studies, seven were randomized control trials.
- Follow up periods tended to be short, ranging from assessing outcomes on the same day as exposure to one year period after the intervention. Five of the eight included studies had follow-up periods of two months or less.
- Lack of consistency in outcome measures and metrics for reporting them made it more difficult to derive summary effect estimates and assess effect magnitudes.
- Studies assessed intervention effectiveness among children (1 study) and adults (6 studies), and a median of 84% of intervention participants were white (6 studies).
- Participants tended to be of higher than average socioeconomic status, with a median of 91% of adult participants having at least some college education (3 studies).
- Studies were conducted in the U.S. (6 studies), Canada (1 study) and France (1 study). Settings included beaches (5 studies), ski resorts (2 studies), and a golf club (1 study). In five studies, interventions were implemented at multiple sites.
- Interventions included education (3 studies), environmental changes, including provision of free sunscreen (1 study), or a combination of both (4 studies).
- Many interventions at beaches included appearance based messages to persuade participants to reduce intentional sun tanning. In contrast, interventions at golf courses or ski resorts, where excessive UV exposure is usually incidental to recreational activity or sporting activity, usually emphasized messages about the importance of sun protection (e.g., use of sunscreen, protective clothing, hat/helmet, sunglasses/ski goggles) while engaged in outdoor activity.
Based on results for interventions in different settings and populations, findings are applicable to the following:
- Diverse outdoor recreational and tourism settings and activities, including places where people go to be exposed to the sun (e.g., beaches) and places where sun exposure is incidental to the recreational activity (e.g., ski resorts, golf courses), provided messages are appropriately targeted to visitors and activities at these settings.
- Adults and children (considering evidence from the updated and original reviews)
An economic review is pending.
Considerations for Implementation
The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.
- Programs in recreational and tourism settings need to consider the small amount of extra time visitors are willing to spend on sun protection interventions and the wide dispersion of people in many of these settings. Strategies may include the following:
- Displaying signage with key messages at a large numbers of locations; using multiple channels to disseminate sun safety messages (e.g., brochures, posters, interactive activities)
- Incorporating sun safety messages into existing activities (e.g., swimming lessons; ski schools)
- Disseminating information at strategic locations, such as waiting areas for tickets or events.
- Providing free sunscreen and ensuring adequate availability of shade may reduce barriers to effective sun protection related to inaccessibility and inconvenience. Providing free sunscreen also removes cost considerations that may cause people to use sunscreen less frequently than they should.
- Sun protection policies appropriate to a specific setting may complement other intervention components focused on educating people about sun safety and making sun protection more accessible. For example, outdoor activities may be scheduled in shaded areas or outside peak UV intensity periods.
- Policy development can play an important role in sustaining and helping to ensure consistent delivery of educational and environmental intervention components. For example, policies may require provision of sunscreen at the pool or incorporate sun safety instruction into curricula for swimming, skiing, or other lessons.
- Interventions may have beneficial consequences beyond individuals’ sun-protective behaviors. For example, programs may decrease risks of overexposure to heat by encouraging people to avoid peak sun exposure or cover up. Programs also can help participants guard against excessive sun exposure that may interfere with healthy outdoor pursuits.
- One ongoing barrier to widespread implementation of these interventions is the belief among some operators of recreational facilities that implementing a sun safety program might adversely affect their business, or that they have no responsibility for their visitors’ sun safety.
- Analytic Framework [PDF - 224 kB]
- Evidence Gaps
- Summary Evidence Table [PDF - 231 kB]
- Included Studies
- Search Strategy
Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.
Community Guide News
- Community-Based Skin Cancer Prevention that Works
Developed by The Community Guide in collaboration with CDC's Division of Cancer Prevention and Control
More promotional materials for Community Guide reviews about Preventing Skin Cancer.
Saraiya M, Glanz K, Briss PA, et al. Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review [PDF - 788 kB]. Am J Prev Med 2004;27(5):422-66.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Preventing skin cancer: interventions in outdoor recreational and tourism settings. www.thecommunityguide.org/cancer/skin/education-policy/outdoorrecreation.html. Last updated: MM/DD/YYYY.
Review completed: April 2014
- Page last reviewed: September 4, 2015
- Page last updated: September 4, 2015
- Content source: The Guide to Community Preventive Services