Ultra-violet radiation (UVR) is a Group 1 carcinogen which causes melanoma and other types of skin cancer, including basal cell and squamous cell carcinoma.1 Exposure to UVR via sun exposure is estimated to cause around 95% of melanoma cases in Australia,2 and excessive childhood sun exposure may impart a particularly high risk for developing melanoma.3 Skin types that have a greater tendency to sunburn are also associated with a greater risk of melanoma.3
Sunburn and sun protection trends over time were analysed by adjusting for important predictors influencing sunburn and sun protection behaviours that otherwise might have biased reported changes over time in response to preventive initiatives. See ‘About the Data’ tab for more detail.
Charts
About this measure
This indicator shows the proportions of adult and adolescent Australians reporting that they had sunburn (i.e. reddening of the skin following sun exposure) and the proportion reporting that they had used a combination of two or more sun protection behaviours on the previous weekend (in summer). Two or more sun protection behaviours were defined as wearing a hat or applying sunscreen, in combination with one other sun protection behaviour defined as wearing a hat, applying sunscreen, wearing at least ¾-length clothing on arms or legs, or staying mostly in the shade.
Data for this indicator are sourced from Cancer Council Australia’s National Sun Protection Surveys from 2003-04 to 2016-17. The surveys are designed to primarily provide a snapshot of sun exposure and sun protection used among adolescents and adults in the Australian community on summer weekends, and do not measure occupational and/or weekday exposure.
In Australia in 2018, the estimated age-standardised incidence rate of melanoma was over 10 times the estimated average global rate.4 Whilst age-standardised melanoma incidence in Australia has declined since 2005, non-age-standardised incidence of melanoma continues to increase, largely due to an ageing population.5 The changes in sun exposure-related behaviours among adolescents is consistent with increased awareness of sun protection and the impact of skin cancer prevention initiatives.6-9
In addition to melanoma, virtually 100% of non-melanoma skin cancers are estimated to be caused by sun exposure.2 Non-melanoma skin cancers were estimated to be the largest cause of hospitalisation from cancer in Australia.10 Melanoma and non-melanoma skin cancer together have the highest cost to the health system of all cancers.11
Current status
In 2016-17, the reported prevalence of sunburn on summer weekends was:
- Higher among adolescents (26%) than among adults (17%).
- Higher among adult males (20%) than among adult females (13%); and
- Higher among adolescent females (28%) than among adolescent males (24%).
In 2016-17, the reported use of a combination of two or more sun protection behaviours on summer weekends was:
- Lower among adolescents (33%) than among adults (47%);
- Similar among adult males (46%) and adult females (48%); and
- Similar among adolescent males (34%) and adolescent females (32%).
Remoteness and socioeconomic status
In 2016-17, the reported prevalence of sunburn on summer weekends was:
- Higher among adults who were non-city residents (19%) than among city residents (15%);
- Higher among adolescents who were non-city residents (32%) than among city residents (23%); and
- Higher among adults living in the middle SES deciles (18%) than those in the lowest SES decile (i.e. highest disadvantage) and highest SES decile (i.e. lowest disadvantage) (12% in each).
In 2016-17, reported use of two or more sun protection behaviours were:
- Similar among adult city residents (47%) and non-city residents (47%).
- Higher among adolescent city residents (36%) than non-city residents (28%).
- Similar among adults in each SES decile (lowest decile - 51%, middle deciles - 47%, highest decile 49%).
International comparisons
National-level data is available for New Zealand which has a similarly high level of melanoma incidence to Australia.2 Among adolescents aged 13-17 years, 17% reported getting sunburnt on the previous weekend (13% for females and 20% for males).12 Among adults aged 18-54 years, 15% report getting sunburnt on the previous weekend.13 Caution should be applied when comparing the Australian and New Zealand data due to the different age ranges for adults and adolescents and other methodological differences (see ‘About the data’).
Trends
Sunburn and sun protection trends over time were analysed by adjusting data for age, sex, skin type, and the weather conditions or ambient ultraviolet radiation (UVR) levels for the date and city relevant to the location and time of respondents’ activities on the weekend. The summary below reflects the findings from multivariate analyses examining the change in prevalence of the indicators over time. The percentages are adjusted prevalence figures from the statistical models and are different from the unadjusted prevalence figures reported in ‘Current Status’. More information about data sources, methods for collection, and guidance for interpreting the data can be found under ‘About the Data’. Note that the use of the terms ‘higher’ or ‘lower’ when describing specific survey years reflects statistically significant differences.
Sunburn prevalence
Sunburn prevalence over time has shown a general decreasing trend among adults and adolescents in Australia.
Over the period from 2003-04 to 2016-17, the adjusted sunburn prevalence for adults was:
- Lower in 2016-17 (11%), 2013-14 (10%), 2010-11 (7%), and 2006-07 (10%) than in 2003-04 (14%);
- Lower among females in 2016-17 (8%), 2013-14 (8%), 2010-11(5%), and 2006-07 (8%) than in 2003-04 (11%); and
- Similar among males in 2016-17 (15%) compared to 2003-04 (16%), after a period of being lower in the intervening years of 2013-14 (12%), 2010-11 (9%), and 2006-07 (12%).
Over the period from 2003-04 to 2016-17, the adjusted sunburn prevalence for adolescents was:
- Similar in the years 2016-17 (16%), 2013-14 (17%), and 2006-07 (21%), compared to 2003-04 (20%). Sunburn prevalence was lower in 2010-11 (13%).
- Similar among females in the years 2016-17 (14%), 2013-14 (15%), and 2006-07 (17%), compared to 2003-04 (19%). Sunburn prevalence was lower in 2010-11 (12%).
- Similar among males in all survey years: 2016-17 (18%), 2013-14 (19%), 2010-11 (15%), 2006-07 (25%), and 2003-04 (20%).
Sun protection behaviour
Sun protective behaviours over time have shown general increasing trends among adults and adolescents in Australia.
Over the period from 2003-04 to 2016-17, the adjusted prevalence for the use of two or more sun protection behaviours for adults was:
- Higher in 2016-17 (45%) and 2006-07 (45%), compared to 2003-04 (41%). The use of sun protection was similar to 2003-04 in the years 2013-14 (43%) and 2010-11 (42%).
- Similar among females in all survey years: 2016-17 (48%), 2013-14 (42%), 2010-11 (47%), 2006-07 (47%), and 2003-04 (45%).
- Higher among males in the years 2016-17, 2013-14, and 2006-07(43% in each year), compared to 2003-04 (38%).
Over the period from 2003-04 to 2016-17, the adjusted prevalence for the use of two or more sun protection behaviours for adolescents was:
- Similar in all survey years: 2016-17 (35%), 2013-14 (24%), 2010-11 (23%), 2006-07 (25%), and 2003-04 (30%).
- Similar among females in all survey years: 2016-17 (32%), 2013-14 (23%), 2010-11 (21%), 2006-07 (16%), and 2003-04 (24%).
- Similar among males in the years 2016-17 (38%), 2013-14 (26%), and 2006-07 (34%), compared to 2003-04 (35%). The use of sun protection was lower in 2010-11 (25%).
Skin cancer control in Australia
The level of UV exposure in Australia has reduced over time, with an increased awareness of skin cancer, use of protective clothing, and the use of sunscreen.7,8 In addition, all Australian states and territories have now banned commercial solariums.14
About the data
This indicator shows the proportion of adult and adolescent Australians reporting that they had sunburn (i.e. any amount of reddening of the skin after being in the sun) and the proportion reporting that they used a combination of two or more sun protection behaviours on the previous weekend (in summer).
Numerator:
1) Adults (aged 18 to 69 years) and adolescents (aged 12 to 17 years) who reported getting sunburnt on the previous weekend (in summer).
2) Adults (aged 18 to 69 years) and adolescents (aged 12 to 17 years) who reported reporting that they used a combination of two or more sun protection behaviours on the previous weekend (in summer). Two or more sun protection behaviours were defined as wearing a hat or applying sunscreen, in combination with one other sun protection behaviour defined as wearing a hat, applying sunscreen, wearing at least ¾-length clothing on arms or legs, or staying mostly in the shade.
Denominator:
Adults (aged 18 to 69 years) and adolescents (aged 12 to 17 years) resident in Australia.
For the purpose of this analysis, ‘city residents’ are defined as residents of the capital cities of Australia’s states and territories. SEIFA refers to Socio-Economic Indexes for Areas. The SEIFA Index of Relative Socioeconomic Disadvantage was used which was derived from residential postcode characteristics. ‘Lowest decile’ refers to areas of greatest disadvantage.
Methodology
Prevalence figures were weighted to be representative of the Australian population with telephones by age, sex and state. For sunburn analyses, data was derived from representative samples of the adult (18-69 years, n=3,614), and adolescent (12-17 years, n=894) residents in Australia in 2016-17. For sun protection behaviours, data was derived from representative samples of the adult (18-69 years, n=2,432), and adolescent (12-17 years, n=684) residents in Australia in 2016-17, and who were outdoors for at least 15 minutes during peak UVR hours on Saturday or Sunday of the designated weekend.
Comparisons of data from earlier National Sun Protection Surveys adjusted for theoretically important predictors influencing sunburn and sun protection behaviours that otherwise might have biased reported changes over time relevant to responses to preventive initiatives. Models were adjusted for age, sex, skin type, and the weather conditions or ambient ultraviolet radiation (UVR) levels for the date and city relevant to the location and time of respondents’ activities on the preceding weekend.
Due to correlations between weather variables and UVR, temperature, cloud cover and wind speed adjusted models were used for sun protection behaviours and UVR adjusted models were used for sunburn. The adjustment for UVR was considered to provide a more rigorous analysis of changes in sunburn over time, given that exposure to different UVR levels can directly determine sunburn outcomes for unprotected skin. Limited UVR and temperature records were available regionally. Therefore, the trend analyses included a subset of respondents for whom the relevant UVR and temperature data were available. These respondents were located within metropolitan areas and were outdoors during peak UVR hours on at least one day of the weekend preceding their interview. For the sunburn analyses, metropolitan residents who were indoors during peak UVR hours on the weekend were also included. Additionally, respondents who were sunburnt at times other than during peak UVR hours on the weekend were excluded from these sunburn analyses.
Data sources
Cancer Council Australia’s National Sun Protection Surveys– 2003-04, 2006-07, 2010-11, 2013-14, 2016-17. Data supplied by the Centre for Behavioural Research in Cancer, Cancer Council Victoria, on behalf of the National Skin Cancer Committee, Cancer Council Australia.
Cancer Council Australia’s National Sun Protection Surveys assess Australian residents’ sun-related knowledge, attitudes and behaviours, and sunburn experiences in weekly cross-sectional telephone interviews over eight weeks in summer. The survey sample frame is selected to obtain a representative sample of Australian residents aged 12 to 17 years and 18 to 69 years in households with a landline telephone. Additional interviews were undertaken in smaller states and the Australian Capital Territory to improve precision of estimates. In 2013-14 and 2016-17, a dual-frame landline/mobile telephone sample was used.
International data
New Zealand data were sourced from the Sun Exposure Survey 2016: Topline Time Series Report (see: https://www.hpa.org.nz/research-library/research-publications/sun-exposure-survey-2016-adult-topline-time-series-report). Data were collected only in areas in which at least one weekend day received a high score using a fine weather criteria standard, for respondents who reported being outdoors for 15 minutes or more between 10am and 4pm. Data from this survey were weighted so that no specific population was over- or under-represented.
Caution should be applied in comparing the Australian and New Zealand data, due to the New Zealand survey being conducted when “fine weather” is present, while the Australian NSPS is conducted across multiple weekends regardless of the weather. This difference in methodology could therefore account for some of the apparent difference in sunburn incidence between the two countries.
Statistical analysis
Cancer Council Victoria performed statistical analysis of the trend data on behalf of Cancer Australia. These multivariate analyses - logistic regression using Stata adjusting for age, sex, skin type, and weather/UV conditions - examined the change in the prevalence of sunburn prevalence and sun protection behaviours over time. The following tables show the outcomes of these analyses:
| Table 1: Australian adults’ sunburn prevalence on summer weekends 2003-2017 | ||||||
| Persons n=12,945 |
Males n=6,177 |
Females n=6,768 |
||||
| % | 95% Cl | % | 95% Cl | % | 95% Cl | |
| 2003-04 (Ref.) | 13.5% | 12.0%-14.9% | 15.7% | 13.4%-17.9% | 11.3% | 9.5%-13.2% |
| 2006-07 | 9.8% | 8.6%-11.1% | 11.9% | 10.0%-13.9% | 7.9% | 6.3%-9.4% |
| 2010-11 | 7.2% | 6.1%-8.3% | 9.4% | 7.5%-11.2% | 5.2% | 3.9%-6.4% |
| 2013-14 | 9.7% | 8.5%-10.8% | 11.9% | 10.0%-13.7% | 7.6% | 6.1%-9.0% |
| 2016-17 | 11.3% | 9.8%-12.8% | 14.6% | 12.1%-17.1% | 8.2% | 6.4%-10.0% |
NOTES: Figures for sunburn on summer weekends were adjusted by age, sex, skin type and mean UVI during peak UVR hours (10am-2pm AEST/11am-3pm DST) among city residents indoors and outdoors. Bold face results used to denote statistically significant change in survey year compared with referent survey year (2003-04). Note overlapping confidence intervals do not always reflect a non-significant result.
| Table 2: Australian adolescents’ weekend sunburn prevalence on summer weekends 2003-2017 | ||||||
| Persons n=2,317 |
Males n=1,172 |
Females n=1,145 |
||||
| % | 95% Cl | % | 95% Cl | % | 95% Cl | |
| 2003-04 (Ref.) | 19.5% | 14.8%-24.3% | 19.7% | 13.3%-26.2% | 19.4% | 12.4%-26.3% |
| 2006-07 | 20.5% | 15.3%-25.7% | 24.8% | 16.8%-32.8% | 16.5% | 9.8%-23.2% |
| 2010-11 | 13.2% | 9.9%-16.5% | 14.9% | 9.5%-20.3% | 11.5% | 7.9%-15.1% |
| 2013-14 | 17.3% | 13.8%-20.8% | 19.3% | 14.1%-24.6% | 15.2% | 10.5%-19.9% |
| 2016-17 | 15.6% | 11.9%-19.3% | 17.8% | 12.1%-23.4% | 13.5% | 8.8%-18.3% |
NOTES: Figures for sunburn on summer weekends were adjusted by age, sex, skin sensitivity and mean UVI during peak UVR hours (10am-2pm AEST/11am-3pm DST) among city residents indoors and outdoors. Bold face results used to denote statistically significant change in survey year compared with referent survey year (2003-04). Note overlapping confidence intervals do not always reflect a non-significant result.
| Table 3: Australian adults’ use of two or more sun protection behaviours on summer weekends 2003-2017 | ||||||
| Persons n=8,588 |
Males n=4,618 |
Females n=3,970 |
||||
|
% |
95% Cl |
% |
95% Cl |
% |
95% Cl |
|
|
2003-04 (Ref.) |
40.7% |
38.2%-43.2% |
37.6% |
34.3%-40.9% |
44.5% |
40.9%-48.2% |
|
2006-07 |
44.8% |
42.0%-47.6% |
42.8% |
39.0%-46.6% |
47.1% |
42.9%-51.3% |
|
2010-11 |
42.1% |
39.6%-44.6% |
38.0% |
34.7%-41.3% |
47.2% |
43.5%-50.9% |
|
2013-14 |
42.5% |
40.0%-44.9% |
42.5% |
39.3%-45.7% |
42.3% |
38.7%-45.8% |
| 2016-17 | 45.4% | 42.2%-48.5% | 43.1% | 38.8%-47.4% | 48.3% | 43.6%-52.9% |
NOTES: Figures for two or more sun protective behaviours on summer weekends adjusted by age, sex, skin sensitivity and weekend temperature, cloud cover and wind conditions. Bold face results used to denote statistically significant change at the p<0.05 level in survey year compared with referent survey year (2003-04). Note overlapping confidence intervals do not always reflect a non-significant result.
| Table 4: Australian adolescents’ use of two or more sun protection behaviours on summer weekends 2003-2017 | ||||||
|
Persons n=1,791 |
Males n=950 |
Females n=841 |
||||
|
% |
95% Cl |
% |
95% Cl |
% |
95% Cl |
|
|
2003-04 (Ref.) |
30.2% |
24.1%-36.2% |
35.4% |
26.9%-43.8% |
23.8% |
15.1%-32.6% |
|
2006-07 |
25.1% |
18.6%-31.6% |
34.2% |
24.1%-44.3% |
15.7% |
8.1%-23.2% |
|
2010-11 |
23.2%† |
19.2%-27.1% |
25.1% |
19.3%-31.0% |
21.3% |
15.8%-26.7% |
|
2013-14 |
24.3% |
19.7%-28.9% |
25.6% |
19.2%-32.0% |
23.3% |
16.7%-29.9% |
| 2016-17 | 35.2% | 28.9%-41.5% | 37.9% | 28.8%-46.9% | 31.9% | 23.2%-40.6% |
NOTES: Figures for two or more sun protective behaviours on summer weekends adjusted by age, sex, skin sensitivity and weekend temperature, cloud cover and wind conditions. Bold face results used to denote statistically significant change at the p<0.05 level in survey year compared with referent survey year (2003-04). Note overlapping confidence intervals do not always reflect a non-significant result.
†The difference in prevalence of use of two or more sun protection behaviours between 2003-04 and 2010-11 was statistically significant as reported in the analyses for the 2010-11 National report15, weighted to the Australian population in 2010, providing weak evidence of an improvement overall for 2010-11.
References
Activity in this area:
Cancer Council Victoria, National Sun Protection Surveys, 2003-4 to 2013-17
Cancer Council Victoria, Centre for Behavioural Research in Cancer – Skin cancer prevention research and evaluation:
http://www.cancervic.org.au/research/behavioural/cbrc-skin
Cancer Council NSW – SunSmart program. http://www.cancercouncil.com.au/cancer-prevention/sun-protection/sunsmart-program
Cancer Institute NSW, Skin cancer campaigns, 2005-06 to 2017-18. https://www.cancerinstitute.org.au/how-we-help/cancer-prevention/skin-cancer-prevention/campaigns
Sunsmart program Victoria - jointly funded by Cancer Council Victoria and the Victorian Health Promotion Foundation (VicHealth) since 1988. http://www.sunsmart.com.au/about/sunsmart-program
Cancer Council Queensland – Skin cancer prevention. https://cancerqld.org.au/cancer-prevention/understanding-risk/being-sunsmart
Cancer Council Western Australia – SunSmart. https://www.cancerwa.asn.au/prevention/sunsmart
Cancer Council SA. SunSmart Program information. https://www.cancersa.org.au/cut-my-risk/sunsmart/sunsmart-information/sunsmart-program-information
Cancer Council Tasmania. Be SunSmart. http://www.cancertas.org.au/prevent-cancer/sunsmart
Cancer Council ACT. SunSmart. http://www.actcancer.org/prevention/sunsmart
Cancer Council Northern Territory. Sun Protection. https://www.cancer.org.au/nt
References:
1. International Agency for Research on Cancer. Personal Habits and Indoor Combustions. Volume 100D. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Lyon: IARC, 2012.
2. Olsen CM, Wilson LF, Green AC, Bain CJ, Fritschi L, Neale RE, Whiteman DC. Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Aust N Z J Public Health 2015; 39:471-6.
3. Nikolau V, Stratigos AJ. Emerging trends in the epidemiology of melanoma. Br J Dermatol. 2014;170:11–19.
4. Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. Available from: https://gco.iarc.fr/today, accessed 08 October 2018.
5. Whiteman DC, Green AC, Olsen CM. The growing burden of invasive melanoma: projections of incidence rates and numbers of new cases in six susceptible populations to 2031. J Invest Dermatol 2016; 136: 1161-1171
6. Doran CM, Ling R, Byrnes J, et al. Benefit Cost Analysis of Three Skin Cancer Public Education Mass-Media Campaigns Implemented in New South Wales, Australia. PLoS One. 2016;11(1):e0147665
7. Makin JK, Warne CD, Dobbinson SJ, et al. Population and age-group trends in weekend sun protection and sunburn over two decades of the SunSmart programme in Melbourne, Australia. Br J Dermatol. 2013;168(1):154-61
8. Volkov A, Dobbinson S, Wakefield M and Slevin T. Seven-year trends in sun protection and sunburn among Australian adolescents and adults. Aust N Z J Public Health. 2013;37(1):63-9
9. Dobbinson SJ, Volkov A and Wakefield MA. Continued Impact of SunSmart Advertising on Youth and Adults' Behaviors. Am J Prev Med. 2015;49(1):20-8
10. Australian Institute of Health and Welfare 2017. Cancer in Australia 2017. Cancer Series no. 101. Cat no. CAN 100. Canberra, AIHW: 205.
11. Australian Institute of Health and Welfare 2013. Health system expenditure on cancer and other neoplasms in Australia: 2008–09. Cancer series no. 81. Cat. no. 78. Canberra: AIHW.
12. Health Promotion Agency (2016). Sun Exposure Survey 2016: Youth report. Wellington: Health Promotion Agency. This document is available at: http://www.hpa.org.nz/research-library/research-publications
13. Trowland, H., Thimasarn-Anwar, T., Dallas, S., McBride-Henry, K., Minster, J., & Bell, R. (2016). Sun Exposure Survey 2016: Adult Topline Time Series Report. Wellington: Research and Evaluation Unit, Health Promotion Agency. This document is available at: http://www.hpa.org.nz/research-library/research-publications
14. Sinclair CA, Makin JK, Tang A, et al. The role of public health advocacy in achieving an outright ban on commercial tanning beds in Australia. Am J Public Health. 2014;104(2):e7-9
15. Volkov, A and Dobbinson, SJ 2011. 2010–11 National Sun Protection Survey Report 2. Australians’ sun protective behaviours and sunburn incidence on summer weekends, 2010–11 and comparison with 2003–04 and 2006-07. Prepared for National Skin Cancer Committee, Cancer Council Australia. Melbourne, Australia, Centre for Behavioural Research in Cancer, Cancer Council Victoria.