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Skin Cancer: Interventions in Outdoor Recreational and Tourism Settings


What the CPSTF Found

About The Systematic Review

This CPSTF 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 CPSTF 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 CPSTF finding on Educational and Policy Approaches in Outdoor Recreational Settings Among Adults and Children pdf icon [PDF - 296 KB].


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.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 235 KB]

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.

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).

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.


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)

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help fill remaining gaps in the evidence base. (What are evidence gaps?)

  • Most of the available evidence comes from studies of predominantly white people with sun-sensitive skin. Future research should attempt to include understudied groups such as other racial/ethnic groups, people with less sun-sensitive skin, and people of lower socioeconomic status.
  • To allow for better understanding of the maximally effective mixture of intervention components, it would be helpful for researchers to assess how intervention effectiveness varies based on the specific combination of components.
  • Studies that follow participants for longer time periods would provide useful information about whether behavior changes are sustained over time and in different contexts.
  • More studies are needed to evaluate interventions that include sun protection policies.
  • It would be helpful for skin cancer researchers to adopt a set of standardized and readily interpretable outcome measures to evaluate the effectiveness of these interventions.

Study Characteristics

  • 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.