Our campaign to reduce the incidence of skin cancer in Western Australia (WA), SunSmart, was established in 1980 and has made a significant impact on improving sun protection practices in WA. But there is still work to be done.
Ultraviolet (UV) radiation from the sun is the major cause of skin cancer, accounting for 99 per cent of non-melanoma skin cancer and up to 95 per cent of melanoma in Australia. Skin cancer is largely preventable by reducing overexposure to UV radiation.
Australia has one of the highest rates of skin cancer in the world, and skin cancer is the most common cancer type in Australia. The burden of this disease and its financial impact on the Australian health system makes skin cancer a significant public health issue.
There were more than 87,000 skin cancer treatments in WA in 2014 and 208 deaths attributed to skin cancer in 2018 in WA. Skin cancer also causes a significant financial burden in WA which is estimated to be in excess of $90 million each year.
In 2012-2016, males and females with melanoma of the skin had a 90 per cent and 94 per cent chance respectively of surviving for at least five years after diagnosis. In 2015/16, $842 million in health system expenditure was attributed to high sun exposure.
Children and adolescents
Childhood and adolescence are periods during which exposure to UV radiation is more likely to contribute to skin cancer in later life. This is due in part to the disproportionately large amount of UV exposure received before age 20, and the fact that children have thinner skin than adults. In addition, adolescents' sun protection behaviours are historically poor when compared with adults.
It is estimated that outdoor workers in Australia receive up to 10 times the UV radiation of those who work primarily indoors. The risk of squamous cell carcinoma among outdoor workers is nearly double that of indoor workers while the risk of basal cell carcinoma is increased by almost 1.5 times. Self-employed tradespeople are a subgroup of particular importance as they are not governed by occupational health and safety regulations (including sun protection policies) that may be present in larger companies.
Rural and regional Australians
In contrast with many other cancer types, the incidence of melanoma is lower in very remote areas of Australia than in major cities; this may be due to the high proportion of Aboriginal people living in these areas, who have a reduced risk of skin cancer. However, people residing in outer and inner regional areas have higher rates of skin cancers compared with their metropolitan counterparts. This may be due in part to a higher proportion of the regional workforce participating in the agriculture, fishing and forestry sectors, which often includes outdoor labour.
SunSmart WA is a comprehensive public education campaign funded by WA Department of Health's Cancer and Palliative Care Network, Healthway, and Cancer Council WA. The first campaign aired in 1981, with Healthway funding the first State run, the annual summer campaign was launched 13 years later. The overall objective of the SunSmart WA program and campaigns is to reduce the incidence of skin cancer by improving sun protection practices among the WA population. SunSmart WA also aims to improve early detection of skin cancer by motivating adults to self-check their skin and seek prompt medical attention as required.
Over the past 40 years, SunSmart WA has broadcast a range of campaigns. By far the most well-known and internationally recognisable is the Slip! Slop! Slap! campaign featuring Sid Seagull (seen below), which was first aired in 1981. This campaign was developed at a pivotal time when the risks of overexposure to UV radiation were becoming more clearly understood. The campaign was designed to raise awareness of the risk of UV radiation, increase sun protective behaviours, and change the "sun-baking" mindset that had dominated the preceding decades.
Since the first Slip! Slop! Slap! campaign, a wide variety of specific campaign messages have encouraged the public to be SunSmart. Campaigns have targeted the dangers of tanning, the cumulative effect of sun exposure, understanding the UV Index, and general sun protection. Powerful testimonial campaigns featuring Clare Oliver, Rowan Barrett and Wes Bonny have also reminded the public about the emotional toll of skin cancer and its impact on families.
Of particular note is a world-first campaign about the UV Index which was developed by SunSmart WA in 2012. This was the first mass media campaign designed to educate people about the UV Index and how to use it.
The most recent campaign, 'Don't let the sun see your DNA', was also produced by SunSmart WA, and features a UV camera to show DNA damage beneath the skin that is not visible to the naked eye.
The UV Index campaign
Don't let the sun see your DNA campaign
SunSmart Schools & Early Childhood Education and Care (ECEC) services
The SunSmart Schools Program aims to minimise student and staff exposure to UV radiation at school and during school-associated activities. It has been running in WA since 1998, while the early childhood program commenced in 2005. As at 31 December 2020, there were 355 SunSmart Schools and 508 ECEC services providing SunSmart care to more than 200,000 WA children.
In the absence of a suitable commercial product, SunSmart WA has been developing and producing UV meters since 2013. The meters display a live reading of the local UV level, which provides people in the vicinity with a guideline about when sun protection is required. To date, more than 40 UV meters have been sold to schools, workplaces, and local governments in Australia and New Zealand as educational tools to enhance awareness about UV radiation.
SunSmart / Healthway partnerships
With guidance from SunSmart WA, Healthway have provided partnership to eligible sports, arts, and racing groups in WA since the early 1990s. Objectives of the partnership program include message awareness and structural change in the delivery of events and activities, with the intention of reducing skin cancer and improving sun protection practices in sponsored organisations.
The SunSmart van began operating in WA in 1994. It is a mobile health promotion and community engagement tool that also sells a range of sun protection products. Free sunscreen is made available to patrons at events, and staff provide information about skin cancer and sun protection. The van attends a number of large outdoor community events throughout Perth and surrounding areas and reaches around 150,000 people each year.
Declining skin cancer rates in younger age groups
Since the early 2000s, there has been a substantial decline in melanoma rates in Western Australians aged 40 years and under.1
Age-adjusted incidence rate of melanoma among Western Australians aged 0-39, 1982-2019.
More SunSmart Schools and ECEC services
Over the past two decades, the SunSmart Schools and ECEC programs have helped to protect more than 200,000 Western Australian children from overexposure to UV radiation. Membership of schools and ECEC services has increased significantly since the program's inception. This increase is likely to be beneficial for future sun protective behaviours, as there is evidence that healthy habits developed early in life may be more likely to carry through to adulthood.
Commercial solaria ban
Public education and advocacy played a pivotal role in the Australia-wide ban of commercial solaria. The Clare Oliver testimonial campaign drew significant attention to the dangers of solaria and helped gain public support. The campaign featured Clare, a young woman who developed a deadly melanoma which she attributed to solaria use. Solariums were officially banned in WA on 1 January 2016.
Claire Oliver. View Claire Oliver's testimonial video campaign.
Change in knowledge and attitudes
Since 1999, SunSmart campaigns have been regularly evaluated by telephone surveys of Western Australian adolescents and adults. A total of 600 respondents participated in surveys each year between 1999 and 2020, and reported sun protective behaviours, as well as attitudes towards and awareness of SunSmart WA campaigns. Campaign evaluation shows that during the last decade, between 94 per cent and 99 per cent of Western Australian adults and adolescents who recalled SunSmart campaigns thought they were believable, and between 35-58 per cent of those who had seen a SunSmart campaign said it had made them more likely to use sun protection2,3.
Decline in preference for a tan
Preference for a tan has declined significantly since 2005/06 when a survey of 600 Western Australians found that nearly two-thirds (63 per cent) of adolescents and just under half (45 per cent) of adults liked to get a suntan. By 2013/14, tanning preference reached its lowest point since 2001/2002, with 33 per cent of adolescents and 23 per cent of adults reporting that they liked to have a suntan. However, this preference has subsequently increased and plateaued, with 45 per cent of adolescents and 33 per cent of adults stating in 2019/2020 that they like having a tan2.
Improved UV index awareness
Cancer Council WA's UV Index campaign from 2012 was designed to educate the public about the UV index. During the second year of the campaign, knowledge that 3 was the UV level at which sun protection is required was 19 per cent in WA, while in states where the campaign was not aired this ranged from 4-9 per cent 4.
The media landscape has changed significantly since SunSmart campaigns began in WA in 1981. Historically, campaigns placed a significant proportion of investment into traditional media, including free-to-air television, radio, out-of-home, cinema, and print. While these channels still have a significant role to play in reaching target audiences, the media landscape has changed with the expansion into digital platforms such as website advertising, social media, audio streaming, and geo-targeting-based channels. These provide new opportunities to target specific groups with a message that is crafted for the platform. Today, the SunSmart campaigns utilise a broad range of traditional channels such as those mentioned above, alongside newer digital channels.
For the first time in 20 years, the SunSmart campaign in WA is facing an uncertain future due to a decline in funding, while advertising costs have increased due to the changing media landscape and inflation. Greater reach and impact of SunSmart campaigns could be achieved with a modest increase in investment, and would mean the campaign could be delivered at best practice levels.
SunSmart WA research shows without sustained efforts the gains we have made over the last 20 years can be lost. Following a succesful anti-tanning campaign, we saw a decline in teenagers' preference for a tan. However, in the absence of dedicated tanning or teen-focused campaigns since that time, we have unfortunately seen preference for a tan increasing once again2.
During the 2021 WA State election, Cancer Council WA sought a $2.2 million annual commitment to skin cancer prevention from the new government, a drop in the ocean compared to the $90 million spent on skin cancer treatment.
Lack of public shade regulation
There is no legislative requirement in WA to include shade in the design of new buildings, facilities or public spaces, nor legislation outlining what the minimum standards of the shade should be; this is despite evidence that well planned and constructed shade can reduce UV exposure by up to 75 per cent. Consequently, new buildings, including playgrounds, are frequently constructed with insufficient shade to provide protection against UV radiation.
Portrayal of tanning and fashion by the media
Tanned skin and brief clothing are often promoted by mainstream media as attractive and fashionable, rendering them desirable for many Australians. Ironically, even media coverage about skin cancer and protection is frequently accompanied by pictures of people wearing brief clothing at the beach, which further perpetuates this problem.
Public misconceptions about sunscreen safety
Despite the evidence that sunscreen reduces skin cancer risk, some Australians hold misconceptions about the safety of sunscreen. These misconceptions may be fuelled by the sharing of misinformation about cancer risk factors through social media and other online channels.
Access to medical practitioners and treatment in remote and regional areas
People living in regional and remote areas generally have poorer access to health services, including GPs and skin specialist services. This disparity in access, coupled with the long travel time for medical treatment, may lead to delay in diagnosis or treatment.
Concerns about vitamin D
Research indicates that some Australians reduce their sun protective behaviours due to concerns about insufficient vitamin D6.
Improvements in understanding of the effect of UV radiation on human skin continue every year. These, combined with new treatment options such as immunotherapy for melanoma, may mean that skin cancer becomes a more easily treatable condition in the future. Until then, prevention must remain the focus of the SunSmart program.
SunSmart seeks to change state and local planning regulations that would see adequate share as a requirement in new public infrastructure. Shade provision has the potential to reduce exposure to harmful UV radiation while at the same time improving the amenity of community facilities, potentially reducing energy costs and creating more liveable neighbourhoods.
Ensuring that the SunSmart message remains evidence-based into the future will inevitably mean that it will need to evolve in line with new scientific discoveries. For example, there have been recent advances in our understanding of the links between UV radiation and human genetics, the role of vitamin D, and implications of sun exposure for conditions such as myopia. These developments have the potential to affect the framing of sun protection messaging. Similarly, the effects of climate change on the SunSmart message will need to be monitored and incorporated as required.
SunSmart WA will continue to focus on self-employed tradespeople. Although there are challenges in reaching this demographic group, there are significant opportunities for reducing their risk of skin cancer through simple behavioural changes regarding use of personal sun protection while at work.
As with all public health messages, a sustained effort is vital to ensure that the very significant gains made in previous years are not lost. It remains as important as ever for sun protection to be front-of-mind for the Australian public, so that complacency or a lack of awareness of the message does not put future generations at risk.
SunSmart is proud of the program's achievements but acknowledges that there is more work to be done. We will strive to continue delivering an effective, evidence-based, multi-faceted public health prevention program to the WA community.
- WA Cancer Registry, Cancer incidence in Western Australia 1982-2019 (unpublished) 2021: Perth: Department of Health, Western Australia.
- Dana, L.M., Grant, H., Talati, Z., Alexander, E., and O'Connor, M., Evaluation of the 2019/20 "UV Camera - Don't let the sun see your DNA" Campaign. 2020, WA Cancer Prevention Research Unit (WACPRU): Perth.
- Jalleh, G., C. Lin, and R.J. Donovan, 2010/11 "Dark Side of Tanning" Campaign Evaluation. 2011, Centre for Behavioural Research in Cancer Control, Curtin University.
- Volkov, A. and S. Dobbinson, 2013-14 National Sun Protection Survey. Report 1: Skin cancer prevention knowledge, attitudes and beliefs among Australians in summer 2013-14, 2014, Cancer Council Victoria.
- Jalleh, G., C. Lin, and R.J. Donovan, 2013/14 "UV Index" campaign evaluation. 2014, Curtin University: Perth, Australia.
- Centre for Behavioural Research in Cancer, 2016-17 National Sun Protection Survey Report 1: Skin cancer prevention knowledge, attitudes and beliefs among Australians in summer 2016-17. 2017, Cancer Council Victoria.