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Cutaneous Drug Eruptions
Skin Cancer Prevention
Skin Disease in HIV
ABSTRACT: The United States is experiencing an underrecognized epidemic of skin cancers. To slow the escalating numbers of diagnosed skin cancers and to help lower morbidity rates through early detection, one message that is easily understood and easy to remember should be used by all organizations concerned with public education about skin cancer prevention. "Be Safe. Be SunAWARE." was developed for an American audience to meet these goals.
The United States is experiencing an underrecognized epidemic of skin cancers (Rogers et al., 2010). To slow the escalating numbers of diagnosed skin cancers and to help lower morbidity rates through early detection, one message that is easily understood and easy to remember should be used by all organizations concerned with public education about this disease. "Be Safe. Be SunAWARE." was developed for an American audience to meet these goals (see Figure 1).
Within the U.S. medical community, it is well known that skin cancer is now the most common form of cancer. More new cases are diagnosed annually than the combined incidence of cancer of the breast, prostate, lung, and colon (Skin Cancer Foundation, 2010). According to a study by Rogers et al. (2010), more than 2.1 million Americans are treated for 3.5 million nonmelanoma skin cancers annually. This is more than double the estimate before 2006 of 1.1 million cancers diagnosed annually and reflects huge personal and economic costs in a country already in the midst of a healthcare crisis.
Most members of the U.S. medical community recognize that skin cancers are primarily caused by unprotected exposure to ultraviolet radiation (UVR) and are thus preventable. They further recognize that early detection allows an excellent prognosis-in the case of melanoma, a 99% survival rate for patients whose melanoma is treated early before the tumor has penetrated the epidermis (Skin Cancer Foundation, 2010).
Over the past 20 years, many organizations have launched anti-skin cancer campaigns and created educational programs focusing on two areas: methods of skin cancer prevention (sun protection) and methods of detection (skin checks). These efforts are admirable and have provided crucial sun protection information to the public. They are not, however, sufficient. The numbers of diagnosed skin cancers continue to rise, and although many of these cancers may be attributed to lifestyles and behaviors of earlier years, the impact of education on current behavior is questionable. A study published by the American Journal of Preventative Medicine (Coups, Manne, & Heckman, 2008) found that the majority of more than 28,000 adults surveyed engaged in at least two cancer behavior risks, such as not using sun-protective clothing, infrequent use of sunscreens with a sun protection factor (SPF) of 15 or greater, indoor tanning, and getting sunburned. Further, Healthy People 2010, which defines national health objectives for the United States, listed in its summary of objectives the goal, "to increase the proportion of persons who use at least one sun-protective measure." To achieve this objective, more effective education will be necessary.
There are several reasons that may suggest why skin cancer education efforts are having an unclear and perhaps a lower than anticipated impact on the general public. One is that the ad hoc individualistic nature of current efforts has led to many programs being focused only on children, whereas other significant population segments are overlooked. Another is the presence of a number of different messages that may or may not reflect the current advice of experts.
The need for improved education and understanding of skin cancer prevention and detection is demonstrated by several studies. Younger adults and men, for example, are shown to be less likely to use some form of sun protection, whether it is sunscreen, protective clothing, or shade (Halpern & Kopp, 2004). This may be because they either choose to ignore education efforts or simply do not receive the messages (Swetter et al., 2009). Adults with lower incomes and less education are also less likely to use sunscreens (National Cancer Institute, 2007), and people of color are less likely to have been taught detection methods (Bradford, 2009).
In addition, different messages and presentation methods used by educational programs and campaigns do not reflect the advice from experts, nor does it accurately prioritize the different components of a skin cancer prevention program. For example, sunscreens continue to be cited as the primary source of sun protection in this country while the advice from the World Health Organization (WHO, 2010) as well as organizations such as the American Academy of Pediatrics (AAP, 2010) is now, and has been for many years, to use sun-protective clothing first, with sunscreen used on only the small amount of skin left exposed.
Furthermore, messages that come from the media or outside the skin cancer/medical community are often conflicting and/or confusing. For example, many people hear sound bites about the importance of sun protection but do not have an understanding of how to achieve that protection. Consequently, they do not know to think beyond relying on sunscreens for total protection and are generally unaware that they should use sun-protective clothing, hats, and sun glasses and seek shade. This misperception is then reinforced by the absurdly high SPF ratings on sunscreen labels, which serve only to give a false sense of security to the consumer. The tanning bed industry also adds to the general confusion by publicizing "good" reasons for tanning, such as "a base tan helps prevent burning." To counteract these misperceptions and misinformation, a single clear message is needed that can be picked up and used by the media and other information sources.
A clear message can correct misperceptions about sunscreens and emphasize sun-protective clothing, the first line of defense against sun exposure. A clear message can help change the notion that we need only to worry about children getting burned or that a tan helps keep skin healthy. A clear message can alert the public to protect their eyes and check their skin. One clear, proactive message-repeated by the media and by anti-skin cancer organizations and remembered and embraced by the public-has the potential to improve education, to affect behavior, and to help slow the epidemic of skin cancer in this country.
The ability of a single, clear message to help slow a skin cancer epidemic has been demonstrated in Australia. Between 1931 and 1985, skin cancer mortality rates rose steadily in that country with annual rates of 6% in men and 3% in women (Giles, Armstrong, Burton, Staples, & Thursfield, 1996). In 1980, the "Slip! Slop! Slap!" campaign was introduced by the Cancer Council Victoria (then the Anti-Cancer Council of Victoria). For the next 8 years, this campaign was solely based on the message to avoid skin cancer by reducing exposure to UVR by wearing a shirt ("slip" on a shirt), sunscreen ("slop" on sunscreen) and a hat ("slap" on a hat). Further, over this period, the slogan was adopted by all seven states in that country and became part of the Australian language. Notably, it was not until 1988, 8 years later, that a multifaceted skin cancer program-SunSmart-was introduced.
It can therefore be said that the measurable increase in the use of sun protection methods between 1980 and 1988 in Australia (Montague, Borland, & Sinclair, 2001) was prompted almost entirely by the use of the "Slip! Slop! Slap!" slogan. Furthermore, later data showing a stabilization of mortality rates from melanoma in Australia since 1990 (Giles & Thursfield, 2001) illustrate the impact of these behavior changes within 10 years of the introduction of the slogan.
Although "Slip! Slop! Slap!" is now dated and arguably inappropriate for an American audience, the lesson learned is invaluable: a single, clear message used consistently by all concerned organizations can have a measurable impact in slowing the epidemic of skin cancers.
However, to suggest that all concerned organizations adopt the same message is not to suggest that every organization adopt the same education program or employ the same methods. Many programs, such as the Environmental Protection Agency's SunWise program, are well established and are successful in reaching their target audience. It is more important that unanimous support be given to one message however that message is relayed to the target audience. When one proactive, easy to understand and to remember message is adopted by all organizations, the message is more likely to be picked up and repeated by other sources of health information. When that happens, as witnessed in Australia, the impact will be measurable.
It is the author's opinion that "Be Safe. Be SunAWARE" is the message that will unify and make coherent the many messages the public receives on the topic of skin cancer prevention and detection and provide a strong framework for the education programs that support it.
"AWARE" is an acronym for the five universally accepted steps to prevent and to detect skin cancer (Figure 2). It was originally constructed as an information framework used in Sun Protection for Life (Barrow & Barrow, 2005) to incorporate the most current skin cancer prevention and detection advice for different segments of the population. The nonprofit organization "SunAWARE," founded by the author, has as its mission skin cancer prevention and early detection and uses the slogan as the cornerstone and framework for its public education programs (http://www.sunaware.org).
* A-Avoid unprotected exposure at any time (including tanning beds) and seek shade.
* W-Wear sun-protective clothing, including a hat with a 3-inch brim and sunglasses.
* A-Apply broad-spectrum sunscreen with an SPF of 30+ to any unprotected skin before exposure and reapply every 2 hours while exposed.
* R-Routinely check skin for changes, understand the need for vitamin D, and report concerns to a healthcare provider.
* E-Educate others about the need for sun protection.
The acronym AWARE was designed by the author and edited by Craig Sinclair while director of the WHO Collaborating Centre for the Promotion of Sun Protection. (Sinclair was also director of the Cancer Education Unit of Cancer Council Victoria, the creator of the "Slip! Slop! Slap!" campaign.) The acronym was written for American use but based on scientific studies from around the world and first appeared in Sun Protection for Life (Barrow & Barrow, 2005).
In 2006, Sun Protection for Life (Barrow & Barrow, 2005) won the Gold Triangle Award from the American Academy of Dermatology for excellence in public education of dermatologic issues. During that same year, the Children's Melanoma Prevention Foundation used the acronym to organize lessons for classrooms in Massachusetts. In 2007, the AWARE acronym was carefully adapted to create a slogan for an American audience: "Be Safe. Be SunAWARE." That same year, Coolibar, a manufacturer of sun-protective clothing, began using the SunAWARE advice for customer education, and the Dermatology Nurses' Association (DNA) adopted it for education of nurses and their patients. Two more books, Lake Vacation (Barrow & Maguire-Eisen, 2008) and Pretty Prom: Your Skin Is Pretty Too (Barrow & Maguire-Eisen, 2008), were published for children and teens using the SunAWARE advice. These books both won the 2009 Gold Triangle Awards from the American Academy of Dermatology. In 2010, the Melanoma Foundation of New England and the Maryland Skin Cancer Prevention Program endorsed the SunAWARE acronym. Also in 2010, the DNA agreed to advocate for one unifying message for all concerned organizations and recommended "Be Safe. Be SunAWARE." as the message. The SunAWARE acronym was used in the 2010 "Don't Fry Day" materials by the DNA and by the Children's Melanoma Prevention Foundation, the Women's Dermotologic Society, the Association of Dermatology Administrators and Office Managers, and the Boston University Department of Dermatology.
The SunAWARE slogan meets the criteria for a comprehensive, easy to remember, actionable message. At the most basic level, the message "Be Safe. Be SunAWARE." means what it says and says what it means. It is immediately understandable as cautionary advice about the sun. Further, as a slogan, it is suitable for all ages. "Be Safe. Be SunAWARE." has a straightforward, believable tone that children, teens, and adults can take seriously. The longest running ad in Ad Council history, "Only you can prevent forest fires," created in 1944, had a similar imperative, serious tone.
Although the tone is serious, there are many ways it was made more appealing to children or targeted to other age groups. Walt Disney allowed the character, Bambi, to be used for the forest fire prevention campaign when it was initiated in 1944. Later that same year, Smokey the Bear was introduced and continues to be used today. The cartoon characters were effective in spreading the message, but the slogan remained the same.
Similarly, the "Be Safe. Be SunAWARE." slogan can be spoken by characters or highlighted with graphics. The message for all children, outdoor workers, parents, physicians, and so forth-regardless of the graphics used-stays the same.
The advice provided in the "Be Safe. Be SunAWARE." message is stepped. That is, the first step is to be safe by being aware of the sun. The second step is to follow the specific advice in the SunAWARE acronym. The AWARE advice is then presented in order of priority, and it presents both primary and secondary measures, those endorsed by organizations such as the WHO and the AAP. Briefly, the first, primary action is to avoid exposure to UVR, but if exposed, to wear sun-protective clothing and apply sunscreen. Then, as a secondary measure, check your skin for any changes caused by the exposure and educate others about the importance of these actions to prevent and to detect skin cancers.
A-"Avoid unprotected exposure at any time (including tanning beds) and seek shade" is the most basic action that an individual can take to help prevent skin cancers. The wording was chosen to address concerns about the previous prevailing advice to avoid all exposure by staying indoors during the hours between 10 A.M. and 4 P.M. Unfortunately, this earlier advice was impractical. With the emphasis now placed on avoiding unprotected exposure, the public knows they can be outdoors in the sun as long as they take measures to protect themselves.
W-"Wear sun-protective clothing including a hat with a 3-inch brim and sunglasses." The use of clothing and a hat is considered by the AAP, the DNA, the WHO, and other medical organizations as the first line of protection to be used when exposed to UVR. In the acronym, it is therefore placed first, before sunscreen. Further, the advice carefully includes both hats and sunglasses. These should be viewed as part of the total outfit needed for protection.
A -"Apply broad-spectrum sunscreen with an SPF 30+ before exposure and reapply every 2 hours while exposed" has been placed in the acronym in the appropriate order of priority-not first. This is particularly important as the pharmaceutical industry has had years to convince the public to use sunscreen, at theexclusion of other means of protection. Further, this step provides guidance for SPF ratings, and it explains correct application methods.
R-"Routinely check your skin, understand the need for vitamin D, and report any concerns to your healthcare provider" alerts the individual to the need to watch for signs of skin cancer. This secondary advice is fundamental to lowering the mortality rates associated with skin cancers. Explanations for how to check skin, for example, using the ABCDEs of melanoma, can easily be included in any education program that uses SunAWARE as its framework.
This step also alerts the individual to be aware of the growing concerns about the need for vitamin D and the best methods of obtaining it. The wording of this clause can be changed as science evolves, but at the very least, individuals are made aware of the need for vitamin D, and they are urged to discuss concerns with their healthcare providers.
E-"Educate others about the need for sun protection." Prompting the individual to help educate others places the responsibility for prevention and detection squarely on the shoulders of all Americans. Education about skin cancer should be considered a social responsibility (as it is in Australia) so that generations to come will routinely practice safe habits.
This brief explanation of the SunAWARE acronym also illustrates several points that make the slogan durable. First, it has been written to be flexible. In an abbreviated form, the acronym still provides powerful actionable advice-Avoid unprotected exposure, Wear sun-protective clothing, Apply sunscreen, Routinely check skin, Educate others. In its unabbreviated form, the advice remains consistent, but it can be modified as science evolves.
Having the flexibility to incorporate changing science is necessary to ensure the success of a slogan. This was witnessed during 2007 and again in 2010 when the SunSmart slogan changed, first to "Slip! Slop! Slap! and Wrap!" and later to "Slip! Slop! Slap! Seek! and Slide!" Neither of these later versions caught on. The message had become diluted and unnecessarily complicated, which created confusion and diminished the effectiveness of the slogan. As a consequence, the valuable advice to wear sunglasses and seek shade was muddled, and the public was left to scratch its collective head.
Conversely, the SunAWARE acronym was designed to incorporate change. Since its creation in 2005, three changes have been made: (1) tanning beds were included as a UVR exposure to avoid; (2) the term broad-spectrum was included to emphasize that sunscreen should protect from both UVA and UVB; and (3) the clause "understand your need for vitamin D" was included in response to the recent findings about low vitamin D levels in populations across the country. These changes-made without disturbing the framework or the overall message-illustrate the flexibility and durability of the acronym.
"Be Safe. Be SunAWARE." is clear. This is of paramount importance in a country like the United States, where the government does not control media content nor provides enough financing for a comprehensive educational program. A clear message, with clear actionable steps, used by credible organizations can thereby be picked up by any other information source, without the need for explanation.
Although the SunWise program, adopted from the Australian SunSmart program and currently used by the Environmental Protection Agency, is well put together and thoughtful, its slogan, "Slip! Slop! Slap!" has too many flaws to work in this country. First and foremost, it is hard to imagine that Americans would have any intuitive understanding of the slogan's meaning without having prior understanding of the specific methods for sun protection to which it refers. In addition, the success of that slogan in Australia was in large part driven by the media, which both promoted the slogan and explained its meaning. The anti-skin cancer program in Australia, unlike that in the United States, is supported by a government with strong control of public broadcasting. It was therefore possible to successfully introduce the "Slip! Slop! Slap!" slogan while continuously explaining its meaning. Although the media in the United States does give some attention and support to the anti-skin cancer efforts, it would be prudent to put forth a message that is more easily and immediately understood.
Furthermore, without the support of multiple information outlets repeating the slogan, using "Slip! Slop! Slap!" in school programs may have minimal impact in the United States. Although it may be possible to explain the meaning of the words in the few hours given to these programs, most parents do not readily understand them and may not take the time to read through their children's take-home material. The actions called for are therefore lost when the child forgets the lesson. This argues for adopting a slogan that is easily understood by the whole family outside of school and one that is easy to remember.
The advice in the AWARE acronym can be incorporated into any type of curriculum from preschool to medical school and tailored to audiences from beach goers to construction workers. For example, for construction workers, the "avoid" step can be adopted by employers to suggest actions such as providing tinted windows on machinery, creating shade for break areas, or creating alternative work schedules that help avoid sun exposure during peak UV hours. Similarly, under the same "avoid" action, schools can create lessons about the UV index or help justify the purchase of shade sails for playground areas, change recess or sports practice schedules, and routinely include the risks associated with tanning beds in health classes. In this respect, the acronym becomes a framework for building strong individual programs for a given audience. Such a framework was created for Minnesota outdoor workers with suggestions for protection included in each step in the acronym. Similarly, the Children's Melanoma Prevention Foundation uses the acronym to organize lessons for schools.
Using SunAWARE as a framework can be as simple or as complex as needed by the individual or organization using it. For example, the Web site of the nonprofit organization SunAWARE (http://www.sunaware.org) uses the acronym to organize the multiple scientific studies that support the SunAWARE advice, presentations to outdoor workers have used the acronym as a framework not only to provide basic advice but also to organize ideas for implementing sun protection and skin cancer detection programs, the SunAWARE blog uses the framework to keep areas of discussion about sun protection and skin cancer clearly indexed for easy access, and an index of resources in Sun Protection for Life (Barrow & Barrow, 2005) was created using categories on the basis of the acronym.
Organizations that already have a logo or a mascot can add the SunAWARE slogan as a way to demonstrate solidarity or to enhance their existing message, or they can make changes so that any existing characters can support the SunAWARE slogan. For example, "SunGuard Man," developed by CDC Coalition for Skin Cancer Prevention in Maryland, may say "SunGuard your skin-Be SunAWARE" or "Fight evil Ultraviolet with SunAWARE." This kind of flexibility allows all organizations to find a means to adopt the slogan without unnecessary rewriting or expense.
To help slow the escalating numbers of skin cancers diagnosed annually and to help improve survival rates with early detection, all organizations concerned with public health education are urged to use the same proactive, easy to remember message: "Be Safe. Be SunAWARE."
American Academy of Pediatrics. (2010). Retrieved August 25, 2010, from http://healthychildren.org[Context Link]
Barrow, M. M., & Barrow, J. F. (2005). Sun protection for life: Your guide to a lifetime of healthy & beautiful skin. Oakland, CA: New Harbinger Publications. [Context Link]
Barrow, M., Maquire-Eisen, M. (2008). Lake Vacation. Minneapolis, MN: Langdon Street Press. [Context Link]
Barrow, M., Maquire-Eisen, M. (2008). Pretty Prom: Your Skin Is Pretty Too. Minneapolis, MN: Langdon Street Press. [Context Link]
Bradford, P. T. (2009). Skin cancer in skin of color. Dermatology Nursing, 21(4), 170-177. [Context Link]
Centers for Disease Control and Prevention, National Institute of Health. (2010). Healthy People 2010. Retrieved August 25, 2010, from http://www.healthypeople.gov/document/html/volume1/03cancer.htm
Coups, E. J., Manne, S. L., & Heckman, C. J. (2008). Multiple skin cancer risk behaviors in the U.S. population. American Journal of Preventative Medicine, 34(2), 87-93. [Context Link]
Giles, G., & Thursfield, V. (Eds.). (2001). Trends in cancer mortality Australia 1910-1999. Melbourne: Anti-Cancer Council Victoria. [Context Link]
Giles, G.G., Armstrong, B. K., Burton, R. C., Staples, M. P., & Thursfield, V. J. (1996). Has mortality from melanoma stopped rising in Australia. BMJ, 312(7039), 1121-1125. [Context Link]
Halpern, A. C., & Kopp, L. J. (2004). Awareness, knowledge and attitudes to nonmelanoma skin cancer and actinic keratoses among the general public. International Journal of Dermatology, 44(2), 107-111. [Context Link]
Montague, M., Borland, R., & Sinclair, C. (2001). Slip! Slop! Slap! and SunSmart 1980-2000: Skin cancer control and 20 years of population based campaigning. Health & Behavior, 28(3), 290-305. [Context Link]
National Cancer Institute. (2007). Cancer trends progress report-2007. Retrieved from http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2007&chid=71&coid=711&[Context Link]
Rogers, H. W., Weinstock, M. A., Harris, A. R., Hinckley, M. R., Feldman, S. R., Fleischer, A. B., et al. (2010). Incidence estimate of nonmelanoma skin cancer in the United States 2006. Archives of Dermatology, 146(3), 283-287. [Context Link]
Skin Cancer Foundation. (2010) Skin cancer facts. Retrieved from http://www.skincancer.org/Skin-Cancer-Facts/[Context Link]
Swetter, S. M., Layton, C. J., Johnson, T. M., Brooks, K. R., Miller, D.R., &Geller, A. C. (2009). Gender differences in melanoma awareness between middle-aged and older men with melanoma and their female spouses. Archives of Dermatology, 145(4), 488-90. [Context Link]
World Health Organization, Media Center. (2010). Ultraviolet radiation and human health/protective measures. Retrieved from http://www.who.int/mediacentre/factsheets/fs305/en/index.html[Context Link]
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