Implementation of the SunSmart program and population sun protection behaviour in Melbourne, Australia: Results from cross-sectional summer surveys from 1987 to 2017.

BACKGROUND: Australia has one of the highest skin cancer rates in the world. 'SunSmart' is a multi-component, internationally recognised community-wide skin cancer prevention program implemented in Melbourne, Australia, since summer 1988-1989. Following recent reductions in melanoma rates among younger Australian cohorts, the extent of behaviour change and the potential contribution of prevention programs to this decline in melanoma rates are of interest. Sun protection is a multifaceted behaviour. Measures previously applied to monitor change over time in preventive behaviour for this population focused on individual behaviours. The omission of multiple behaviours that reduce exposure to ultraviolet radiation (UV) may have led to underestimates of behaviour change, meriting further analysis of long-term trends to contribute to this debate. METHODS AND FINDINGS: A population-based survey was conducted in Melbourne in the summer before SunSmart commenced (1987-1988) and across summers in 3 subsequent decades (1988-2017). During summer months, residents (14-69 years) were recruited to cross-sectional weekly telephone interviews assessing their tanning attitudes, sun protection behaviour, and sunburn incidence on the weekend prior to interview. Quotas were used to ensure the sample was proportional to the population by age and sex, while younger respondents were oversampled in some years. The majority of the respondents reported their skin was susceptible to sunburn. Changes in sun protection behaviour were analysed for N = 13,285 respondents in multivariable models, cumulating surveys within decades (1987-1988: N = 1,655; 1990s: N = 5,258; 2000s: N = 3,385; 2010s: N = 2,987) and adjusting for relevant ambient weather conditions and UV levels on weekend dates. We analysed specific and composite behaviours including a novel analysis of the use of maximal sun protection, which considered those people who stayed indoors during peak UV hours together with those people well-protected when outdoors. From a low base, use of sun protection increased rapidly in the decade after SunSmart commenced. The odds of use of at least 1 sun protection behaviours on summer weekends was 3 times higher in the 1990s than pre-SunSmart (adjusted odds ratio [AOR] 3.04, 95% CI 2.52-3.68, p < 0.001). There was a smaller increase in use of maximal sun protection including shade (AOR = 1.68, 95% CI 1.44-1.97, p < 0.001). These improvements were sustained into the 2000s and continued to increase in the 2010s. Inferences about program effects are limited by the self-reported data, the absence of a control population, the cross-sectional study design, and the fact that the survey was not conducted in all years. Other potential confounders may include increasing educational attainment among respondents over time and exposure to other campaigns such as tobacco and obesity prevention. CONCLUSIONS: With an estimated 20-year lag between sun exposure and melanoma incidence, our findings are consistent with SunSmart having contributed to the reduction in melanoma among younger cohorts.

Continued Impact of SunSmart Advertising on Youth and Adults' Behaviors.

INTRODUCTION: Televised advertising campaigns play a central role in public education for skin cancer prevention in Australia. Continued impact on behavior is crucial to optimize these investments. This study examines whether exposure to increased intensity of summer campaigns in the past decade has continued to influence sun protection behaviors and to examine behavioral impact across age groups. METHODS: Cross-sectional weekly telephone surveys of Melbourne residents were conducted over summers from 1987-1988 to 2010-2011, and analyzed in 2012-2014. Respondents' sun-related attitudes and their sun protection and sunburn on the weekend prior to interview were assessed. Population exposure to campaign TV advertising was measured as cumulated weekly target audience rating points (TARPs) for 4 weeks prior to interviews. Multiple logistic and linear regression models examined the relationship of campaign advertising with tanning preference and behavioral outcomes (N=11,881). RESULTS: Respondents' attitudes and behaviors in 1987-2011 were associated with TARPs. Increasing TARPs were related to increased preference for no tan (OR=1.12, 95% CI=1.07, 1.17); sunscreen use (OR=1.09, 95% CI=1.02, 1.17); and overall reduced mean percentage of skin exposed to the sun (B=-0.01, 95% CI=-0.01, 0.00). These effects had limited interaction with time period, age group, gender, or skin type. There was evidence of diminishing returns at the highest TARP quartile for tan preference but not for behavioral outcomes. CONCLUSIONS: Sustained youth-focused advertising campaigns (for adolescents and young adults), when broadcast with sufficient TARPs during the summer months, continue to provide consistent beneficial impact on sun protection behaviors population-wide.

Seven-year trends in sun protection and sunburn among Australian adolescents and adults.

AIMS: To examine the change in sun protective behaviours and sunburn of Australians over a seven-year period, in the context of sustained skin cancer prevention campaigns and programs. METHODS: Weekly cross-sectional telephone interviews of Australians were conducted throughout summer in 2010/11 for comparison with 2003/04 and 2006/07. In 2010/11, n=1,367 adolescents (12-17 years) and n=5,412 adults (18-69 years) were interviewed about their sun-related attitudes, weekend sun protection and sunburn. Multivariate analyses adjusted for key demographics, temperature, cloud, wind and ultraviolet radiation (UVR) to assess change in outcomes over time. RESULTS: There were consistent improvements in adolescents' and adults' attitudes, intentional tanning and incidence of sunburn over time. Behavioural changes were variable. Adults spent less time outdoors during peak UVR compared to past surveys, while adolescents were less likely to be outdoors compared with 2006/07. Sunscreen use and wearing of long sleeves increased among adults, but hat wearing decreased for both age groups, as did leg cover by adolescents since 2003/04. There has been a sustained decrease in weekend sunburn among adolescents and adults. CONCLUSIONS: The findings suggest improvements in skin cancer prevention attitudes of Australians over time. Australians' compliance with sun protection during summer has improved in some areas, but is still far from ideal. The sustained decrease in weekend sunburn among adolescents and adults is encouraging, but further improvements are required.