Executive Summary The Surgeon General’s Call to Action to Prevent Skin Cancer calls on partners in prevention from various sectors across the nation to address skin cancer as a major public health problem. Federal, state, tribal, local, and territorial governments; members of the business, health care, and education sectors; community, nonprofit, and faith-based organizations; and individuals and families are all essential partners in this effort. The goal of this document is to increase awareness of skin cancer and to call for actions to reduce its risk. The Call to Action presents the following five strategic goals to support skin cancer prevention in the United States: increase opportunities for sun protection in outdoor settings; provide individuals with the information they need to make informed, healthy choices about ultraviolet (UV) radiation exposure; promote policies that advance the national goal of preventing skin cancer; reduce harms from indoor tanning; and strengthen research, surveillance, monitoring, and evaluation related to skin cancer prevention. Skin Cancer as a Major Public Health Problem Skin cancer is the most commonly diagnosed cancer in the United States, and most cases are preventable.1–3 Skin cancer greatly affects quality of life, and it can be disfiguring or even deadly.1,4–6 Medical treatment for skin cancer creates substantial health care costs for individuals, families, and the nation. The number of Americans who have had skin cancer at some point in the last three decades is estimated to be higher than the number for all other cancers combined,7 and skin cancer incidence rates have continued to increase in recent years.1,8 Each year in the United States, nearly 5 million people are treated for all skin cancers combined, with an annual cost estimated at $8.1 billion.9 Melanoma is responsible for the most deaths of all skin cancers, with nearly 9,000 people dying from it each year.10 It is also one of the most common types of cancer among U.S. adolescents and young adults.11 Annually, about $3.3 billion of skin cancer treatment costs are attributable to melanoma.9 Despite efforts to address skin cancer risk factors, such as inadequate sun protection and intentional tanning behaviors, skin cancer rates, including rates of melanoma, have continued to increase in the United States and worldwide.1,12–16 With adequate support and a unified approach, comprehensive, communitywide efforts to prevent skin cancer can work. Although such success will require a sustained commitment and coordination across diverse partners and sectors, significant reductions in illness, deaths, and health care costs related to skin cancer can be achieved. Although genetic factors, such as being fair-skinned or having a family history of skin cancer, contribute to a person’s risk,17–23 the most common types of skin cancer are also strongly associated with exposure to UV radiation.3,24–29 As many as 90% of melanomas are estimated to be caused by UV exposure.24,30 UV exposure is also the most preventable cause of skin cancer. The Call to Action focuses on reducing UV exposure, with an emphasis on addressing excessive, avoidable, or unnecessary UV exposures (such as prolonged sun exposure without adequate sun protection) and intentional exposure for the purpose of skin tanning (whether indoors using an artificial UV device or outdoors while sunbathing). UV radiation is a type of electromagnetic radiation emitted by the sun and from some man-made lights, with wavelengths longer than X-rays but shorter than visible light.31,32 UV exposure stimulates melanocytes to produce melanin, often resulting in a tan or sunburn, both of which indicate overexposure and damage to the skin, skin cells, and DNA within those skin cells.33,34 This damage can lead to cancer. The degree to which UV exposure increases a person’s risk of skin cancer depends on many factors, such as individual skin type, the amount and types of sun protection used, whether exposure is constant or intermittent, and the age at which the exposure occurs.14,30,35–40 By reducing intentional UV exposure and increasing sun protection, many skin cancer cases can be prevented.3,24–29 For most people in the United States, the sun is the most common source of exposure to UV radiation. UV radiation from indoor tanning devices is a less common but more easily avoidable source of UV radiation exposure than from the sun. Indoor tanning devices, such as tanning beds, tanning booths, and sun lamps, expose users to intense UV radiation as a way to tan the skin for cosmetic reasons. Although reducing UV overexposure from the sun can be challenging for some people, UV exposure from indoor tanning is completely avoidable. In 2009, the World Health Organization (WHO) classified indoor tanning devices as Class I human carcinogens on the basis of strong evidence linking indoor tanning to increased risk of skin cancer.26 A 2014 meta-analysis estimated that more than 400,000 cases of skin cancer may be related to indoor tanning in the United States each year: 245,000 basal cell carcinomas, 168,000 squamous cell carcinomas, and 6,000 melanomas.41 Initiating indoor tanning at younger ages appears to be more strongly related to lifetime skin cancer risk, possibly because of the accumulation of exposure over time from more years of tanning.42–45 The relationship between outdoor UV exposure, vitamin D, and human health is complex. The amount of outdoor sun exposure needed for meaningful vitamin D production depends on many factors, including time of day, time of year, latitude, altitude, weather conditions, a person’s skin type, amount of skin exposed to the sun, other individual circumstances, and reflective surfaces, such as snow, water, and sand. Adequate vitamin D can be obtained safely through food and dietary supplements without the risks associated with overexposure to UV radiation.46,47 Although all UV exposures can affect skin cancer risk, entirely avoiding UV rays from the sun is neither realistic nor advisable for most Americans. Spending time outdoors is associated with positive health benefits, such as increased levels of physical activity and improved mental health.48–50 Reducing the Risk of Skin Cancer Most skin cancers are at least partially caused by UV exposure, so reducing exposure reduces skin cancer risk. However, one out of every three U.S. adults has been sunburned in the past year, and most do not take recommended actions to protect themselves from the sun.51,52 In addition, indoor tanning rates are high among some groups, such as young, non-Hispanic white females, and skin cancer incidence rates are increasing. These facts show a need to take action to improve sun protection behaviors and address the harms of indoor tanning. Individuals can take steps to reduce their risk of developing skin cancer. Sun protection helps prevent the harmful effects of sun exposure, including sunburn, skin cancer, premature skin aging, and eye damage. When used as part of a comprehensive approach, well-tailored, individual-focused strategies may be effective for reaching specific subpopulations.53,54 According to WHO’s International Agency for Research on Cancer, ideal sun protection involves several behaviors, including wearing tightly woven protective clothing, wearing a hat that provides adequate shade to the whole head, seeking shade whenever possible, avoiding outdoor activities during periods of peak sunlight (such as midday), and using sunscreen (in conjunction with other sun protection behaviors).55 There are barriers to using sun protection. Many Americans lack a general knowledge or awareness about the risks associated with sun exposure, or they think they are at low risk of developing skin cancer or sunburn.56–58 Social norms regarding tanned skin as attractive and healthy create barriers to reducing intentional exposure to UV radiation, whether indoors or outdoors. Intentional tanning, which includes both indoor tanning and seeking a tan outdoors, is strongly associated with a preference for tanned skin and other appearance-focused behaviors.59–62 Women in particular may experience greater social pressure to tan and have tanned skin, which likely explains the higher rates of indoor tanning observed among women than men.59,63–67 Sunburns in childhood are a clear risk factor for skin cancers later in life, and building healthy habits early when children are more receptive can lead to increased sun protection into adulthood.68,69 Given the amount of time children spend in school settings, much of the skin cancer prevention efforts for children have focused on sun-safety education in schools and changes to the school environment to promote sun-safe behaviors. Similar to schools, outdoor work settings are an important setting for efforts to prevent overexposure to the sun and reduce skin cancer risk. Research has shown that skin cancer prevention interventions designed to reach outdoor workers can be highly effective at increasing sun protection behaviors and decreasing sunburns.70 The Guide to Community Preventive Services (The Community Guidea) states that sufficient evidence exists to recommend multicomponent, communitywide interventions,b as well as interventions designed for certain settings (specifically, child care centers, primary and middle schools, outdoor recreational and tourism settings, and outdoor occupational settings).70 Intervention strategies that address social and contextual factors have the potential for broad public health impact by making the healthy choice the easy or default choice.71 Policies, legislation, and regulation are examples of such interventions, reaching wide segments of communities while requiring minimal individual effort compared with interventions directed at individuals.71 Policies that address skin cancer prevention vary across the country. Only a few states, such as California and New York, have passed legislation requiring that schools allow students to use sun-protective clothing (California) or sunscreen (California and New York) on campus.72,73 California law also urges employers to identify and correct workplace hazards connected to UV radiation.74 A few states have passed legislation to support sun-safety education programs and skin cancer prevention awareness. Laws in Arizona and New York mandate instruction on skin cancer prevention as part of the health education curriculum in public schools.75,76 Kentucky passed a law encouraging skin cancer education in schools.77 Some states have policies that reach beyond children as the audience for education and awareness. New York mandates sun-safety education for all state employees that spend more than 5 hours per week outdoors.78 Some states and municipalities in the United States have regulations relating to use of indoor tanning devices. Considerable variation exists throughout the country in the strength and enforcement of indoor tanning restrictions, as well as compliance with these restrictions. In October 2011, California passed the most stringent youth access law in the country, which took effect on January 1, 2012, and prohibits indoor tanning for anybody younger than age 18 years.79 Since then, Vermont, Nevada, Oregon,c Texas, Illinois, Washington,c Minnesota, Louisiana, and Hawaii have also adopted prohibitions on indoor tanning for minors younger than age 18 years.79–81 Currently, at least 44 states and the District of Columbia have some kind of law or regulation related to indoor tanning, including bans on indoor tanning for minors under a certain age (ranging from 14 to 18), laws requiring parental accompaniment or parental permission, or regulations that otherwise reduce harms (such as requiring eye protection).79–85 Indoor tanning laws, particularly those that include age restrictions, appear to be effective in reducing indoor tanning among female high school students, who have the highest rates.86 Federal policies, legislation, and regulations can help prevent skin cancer. The U.S. Department of Health and Human Services (HHS) and its agencies play important roles in skin cancer prevention at the federal level. These agencies include the National Cancer Institute in the National Institutes of Health, the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and the Agency for Healthcare Research and Quality. CDC supports Comprehensive Cancer Control Programs in states, tribes, and territories, many of which conduct activities related to skin cancer prevention. Federal entities outside HHS also address skin cancer prevention, including the Federal Trade Commission, the U.S. Environmental Protection Agency, the National Park Service, and the Occupational Safety and Health Administration. Sunscreens sold in the United States are governed by FDA as over-the-counter drugs. Regulations identify acceptable active ingredients and dosage strengths, provide language and format for product labels, and establish standardized test methods for determining a product’s sun protection factor (SPF), among other requirements. Products that satisfy regulatory conditions are considered to be safe, effective, and truthfully labeled and may be marketed without premarket review and approval by FDA. Products that vary from regulatory conditions may be sold only after FDA review and approval.87 Under the FDA regulations, all sunscreen products are labeled for use to help prevent sunburn, and they must state the product’s SPF. Sunscreens that pass a separate test for broad spectrum (UVA and UVB) protection may also be labeled as “broad spectrum.” In addition, broad spectrum sunscreens with SPF levels of 15 or higher may be labeled as reducing the risk of skin cancer and premature skin aging when used together with other sun protection measures, including limiting time in the sun and wearing long-sleeved shirts, pants, hats, and sunglasses.87 FDA also regulates indoor UV tanning devices under separate authorities, both as medical devices and as radiation-emitting electronic products. On May 29, 2014, FDA reclassified indoor tanning devices to Class II medical devices (moderate to high risk).88,89 Once the reclassification order is effective, manufacturers will have to include a warning that people younger than age 18 years should not use these devices, receive premarket notification 510(k) clearance from FDA for newly marketed devices, and meet other requirements.90 The Surgeon General’s Call to Action to Prevent Skin Cancer is informed by international efforts to prevent skin cancer. Other countries have taken a variety of approaches to prevent skin cancer, including community-based, multicomponent interventions, which are recommended by The Community Guide.70,91 Data from efforts in Australia provide evidence that sustained funding for a community-level skin cancer prevention initiative can improve health outcomes and result in long-term savings in health care costs.92 Many countries have laws specifically addressing indoor tanning. Brazil and New South Wales, Australia, have passed complete bans on indoor tanning.93,94 In addition, as of January 2014, France, Spain, Portugal, Germany, Austria, Belgium, the United Kingdom, Australia, Iceland, Italy, Finland, and Norway prohibit indoor tanning for youth younger than age 18 years.93,94 Gaps in Research and Surveillance Important strides have been made in skin cancer prevention in the United States, but they have not been sufficient to curb the rising rates of skin cancer incidence. Social and behavioral research can help us better understand some issues, such as ongoing high rates of sunburn despite improvements in sun protection and ongoing high rates of indoor tanning despite evidence that it is a human carcinogen. More information is needed regarding effective message framing and effective policies to promote behavior change. Reliable data are also needed to measure the effect of prevention efforts. Many skin cancer cases are not being captured by current surveillance systems, and current behavioral surveillance systems may not be adequate to track the effect of state and local initiatives, such as indoor tanning legislation for minors. Calls to Action This section presents five strategic goals to support skin cancer prevention in the United States. Federal, state, tribal, local, and territorial governments; businesses, employers, and labor representatives; health care systems, insurers, and clinicians; early learning centers, schools, colleges, and universities; community, nonprofit, and faith-based organizations; and individuals and families are all essential partners in this effort. Strategies that change the context or environment to support healthy choices generally have greater reach and are more effective at the population level than strategies focused on individual behavior.71 This section also provides education and communication strategies, which will likely be most effective if used in conjunction with changes to the social context and environment. Involving partners across disciplines, sectors, and institutions will be essential to addressing the rising incidence of skin cancers in the United States. Goal 1: Increase Opportunities for Sun Protection in Outdoor Settings Strategies Increase shade in outdoor recreational settings. Support sun-protective behaviors in outdoor settings. Increase availability of sun protection in educational settings. Increase availability of sun protection for outdoor workers. Goal 2: Provide Individuals with the Information They Need to Make Informed, Healthy Choices About UV Exposure Strategies Develop effective messages and interventions for specific audiences. Support skin cancer prevention education in schools. Integrate sun safety into workplace health education and promotion programs. Partner with health care systems and providers to implement and monitor use of recommended preventive services for provider counseling on skin cancer prevention. Establish partnerships between public and private sectors to disseminate effective messages about skin cancer prevention. Enhance ongoing engagement of federal partners to advance our nation’s skin cancer prevention efforts. Goal 3: Promote Policies that Advance the National Goal of Preventing Skin Cancer Strategies Support inclusion of sun protection in school policies, construction of school facilities, and school curricula. Promote electronic reporting of reportable skin cancers and encourage health care systems and providers to use such systems. Incorporate sun safety into workplace policies and safety trainings. Support shade planning in land use development. Goal 4: Reduce Harms from Indoor Tanning Strategies Monitor indoor tanning attitudes, beliefs, and behaviors in the U.S. population, especially among indoor tanners, youth, and parents. Continue to develop, disseminate, and evaluate tailored messages to reduce indoor tanning among populations at high risk. Support organizational policies that discourage indoor tanning by adolescents and young adults. Enforce existing indoor tanning laws and consider adopting additional restrictions. Address the risks of indoor tanning with improved warning labels and updated performance standards. Goal 5: Strengthen Research, Surveillance, Monitoring, and Evaluation Related to Skin Cancer Prevention Strategies Enhance understanding of the burden of skin cancer and its relationship with UV radiation. Evaluate the effect of interventions and policies on behavioral and health outcomes. Build on behavioral research and surveillance related to UV exposure. Quantify the prevalence of tanning in unsupervised locations. Conclusion With this Call to Action, the U.S. Surgeon General emphasizes the need to act now to solve the major public health problem of skin cancer. To reduce skin cancers in the population, people must get the information they need to make informed choices about sun protection, policies must support these efforts, youth must be protected from harms of indoor tanning, and adequate investments need to be made in skin cancer research and surveillance. Achieving these goals will not be a small task. It will require dedication, ingenuity, skill, and the concerted efforts of many partners in prevention across many different sectors. Many of these partners are already enthusiastically involved, but greater coordination and support are needed to increase the reach of their efforts. The goals and strategies outlined in the Call to Action are the next steps. We must act with urgency to stop the ever-increasing incidence of skin cancers in the United States. 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