Some skin cancers can be prevented by limiting time spent in strong sunlight. Far too many people think of sunscreen as the only form of sun protection.
Photo: Sturlason
In Norway, Easter is associated with holidays in the mountains or southern Europe, plenty of sunshine and a tan. However, as most people are aware, the more we expose ourselves to UV radiation from the sun without protection, the higher the risk of developing skin cancer. The advice from the Norwegian Cancer Society and public health authorities for many years has therefore been to limit time in strong sunlight, seek shade, protect the skin with clothing when appropriate, wear a sun hat, apply high-SPF sunscreen, and avoid using sunbeds (1) . In short: everything in moderation. This is advice that dermatologists are giving to people every day.
Studies, however, show that sun habits vary considerably among the population (2, 3) . Far too many people think of sunscreen as the only form of sun protection. Many use it as the only form of sun protection, and its application is often flawed. According to a group of around 40 international leading skin cancer experts (5) , this may have played a role in the increasing incidence of melanoma, squamous cell carcinoma and basal cell carcinoma in countries where a large proportion of the population has fair skin (4) . The group has recently introduced a Protect your Skin Check Box with five sun safety recommendations, which they would like to see used in future public awareness campaigns.
The group has recently introduced a Protect Your Skin Check Box with five sun safety recommendations, which they would like to see used in future public awareness campaigns
The first item on the checklist is: Avoid sunbathing and tanning (5) . This advice is far more explicit than the current recommendations from the Norwegian Cancer Society (1) . The second item is: Do not use sunbeds . The other recommendations are also explicit: when the UV index is 3 (i.e. moderate) or higher, direct sun exposure should be avoided for two hours before and after midday. The skin needs to be protected from the sun, preferably with clothing and a wide-brimmed hat, and sunscreen with at least SPF 30 and UVA protection should be applied to all areas of skin that cannot be protected by clothing. The skin cancer experts assert that we need to change people's attitudes to UV exposure (5) , implicitly: challenging today's tanning culture.
The incidence of skin cancer is also rising in Norway (6) . The incidence and mortality of melanoma have long been much higher than in most other European countries (6, 7) . Admittedly, thin melanomas with a good prognosis after excision account for a large proportion of the increase in melanoma cases (8) , and some of the rise is likely due to overdiagnosis (9) . The mortality rate for melanoma has decreased slightly in recent years, probably due to new treatment options for advanced disease, while the mortality rate for squamous cell carcinoma has remained low and stable despite an increasing incidence (6) . Nonetheless, the rising incidence of skin cancer is concerning, as the cost to society of diagnosis and treatment are substantial and continue to increase. For those affected, skin cancer can involve repeated, sometimes extensive, operations with prominent scars and sequelae, burdensome medications for advanced disease and, in the worst case, death.
Some of the recommendations from the international expert group are controversial and are likely to meet resistance, at least in Norway. The group has the best intentions, but it is uncertain whether such strict advice on sun exposure for the general population will lead to healthier sun habits and a lower incidence of skin cancer. We all tend to ignore advice we do not like. Changes in attitudes and cultural practices take time. The fight to combat smoking took time and was ultimately won (in our part of the world), but unlike the sun, tobacco and tobacco smoke have no biological function.
Sunlight plays a part in many important biological processes in the body. It regulates circadian rhythms and provides us with energy. We enjoy spending time in good weather, especially in a country like Norway. The expert group makes no mention of such positive health benefits (5) . Recommendations on healthy sun practices should also be balanced with other public health advice, such as spending time outdoors, staying physically active and socialising. It is not only skin cancer that entails significant societal costs: the same is true for physical inactivity, sedentary lifestyles and loneliness – factors that rank among the greatest health challenges of our time.
Recommendations on healthy sun practices should also be balanced with other public health advice, such as spending time outdoors, staying physically active and socialising
Health education is challenging. Some people will take good advice about their health too literally and develop anxiety around the issue, while others will ignore advice they do not like or do not believe in. The expert group makes many valid points that we need to consider (5) . It is not healthy to lie in the sun for long periods to get a tan. However, we must not take away people's enjoyment of good weather, physical activity and spending time outdoors. The challenge is to devise sun safety recommendations that the public will accept, remember and follow, while balancing these with other factors besides the risk of skin cancer.