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Sunscreen use while driving

Dennis P. Kim, MD,a Indy Chabra, MD, PhD,c Pawan Chabra, MA,d and Evan C. Jones, MD, MPHb Stony Brook, New York; Dakota Dunes, South Dakota; and Pittsburgh, Pennsylvania
Background: Data regarding patient perceptions and behaviors about sun-protection measures while driving are lacking. Objectives: This study evaluates patients awareness of the importance of sun protection while in an automobile, and assesses perceptions about and compliance with sun protection. A secondary objective was to detect any signicant laterality in melanoma and nonmelanoma skin cancers. Methods: We performed a retrospective survey of patients seen at a Mohs micrographic surgery clinic. Results: Signicantly fewer patients reported wearing sunscreen while in an automobile when compared with general daily sunscreen use (52% vs 27%, P \ .05). Most respondents did not think they needed to use sunscreen while driving, especially if the windows were closed. Those who believed they were protected from sun damage while in a car were much less likely to use sunscreen (12% vs 46%, P \ .05). There was a significant left-sided predominance of nonmelanoma skin cancers, except in patients who used automobiles with tinted windows. Limitations: This retrospective survey study design is not as ideal as a randomized controlled trial. Additional limitations of this study include small sample size, selection bias, and recall bias. Conclusion: Our results reveal poor patient awareness of and compliance with sun-protection measures while in an automobile. Skin cancer prevention efforts should be modied to specically address automobile-related sun exposure. ( J Am Acad Dermatol 2013;68:952-6.) Key words: driving; laterality; melanoma; skin cancer; sun protection; sunscreen; ultraviolet.

ecent studies have demonstrated that time spent in vehicles is an important and underrecognized source of ultraviolet (UV)A exposure.1 In a 2009 survey examining sun exposure, driving constituted the largest percentage of total time spent outdoors, more than outdoor activities such as exercise or gardening.2 Studies estimate the average time spent in a car at 80 to 100 minutes per day.3,4 Because such a large portion of a persons cumulative sun exposure occurs while in a vehicle, automobile-related UVA exposure is a considerable public health concern.

Abbreviations used: MM: NMSC: UV: UVR: malignant melanoma nonmelanoma skin cancer ultraviolet ultraviolet radiation

automobile, and assesses patients perceptions about and compliance with different sun-protection measures. A secondary objective was to detect any signicant laterality in melanomas and nonmelanoma skin cancers (NMSC).

RATIONALE
This study evaluates patients awareness of the importance of sun protection while in an
From the School of Medicinea and Department of Dermatology,b Stony Brook University; Midlands Clinic, Dakota Dunesc; and Department of Statistics, University of Pittsburgh.d Funding sources: None. Conflicts of interest: None declared. Accepted for publication December 13, 2012.

METHODS
We performed a retrospective survey of patients seen at our Mohs micrographic surgery clinic. All
Reprint requests: Evan C. Jones, MD, MPH, Department of Dermatology, Health Sciences Center, Level 16, Room 060, Stony Brook, NY 11794-8165. E-mail: ejones7@hotmail.com. Published online February 5, 2013. 0190-9622/$36.00 2012 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2012.12.964

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patients provided written informed consent, and the respondents believed that the sun could still damage institutional review board reviewed and approved their skin when the car windows were closed. There the protocol. Patients were asked about their driving was no statistically significant difference between habits and medical history, including time spent those with and without a personal history of skin driving with an open window or in a car with tinted cancer in this regard. Consistent with their beliefs, windows, recreational activities, sunscreen use, famthose who reported thinking they were protected by ily history of skin cancer, skin type, and their site and closed windows were much less likely to think they type of skin cancer. Patients needed to use sunscreen were also asked about their while driving than those CAPSULE SUMMARY frequency of sunscreen use who did not believe they while in an automobile and were protected. The average American spends up to 2 their impressions about sun hours in a vehicle each day, leading to protection provided by sunclinically relevant exposure to ultraviolet screen, car windows, and Use of sun-protection radiation, even when windows are window tinting. The impact measures closed. of age, gender, personal and When asked about genDespite awareness that sun-exposure family history of skin cancer, eral sunscreen use, 38% of while driving can damage the skin, only number of reported hours responders reported using a small minority of patients use driven, and recreational acsunscreen most of the time. sunscreen while in an automobile. tivity was assessed by linear This decreased to 15% when regression analysis using asked about sunscreen use Patients need to be educated about the software (SPSS 19, SPSS Inc, while in a vehicle. There was need for sun protection while in a Chicago, Ill). All statistically no signicant difference bevehicle. signicant values were tween those with or without 2-sided with a P value of a personal history of skin less than .05. cancer despite the differences in awareness described above. With respect RESULTS to window tinting, 53% had automobiles with tinted Patient characteristics windows, and the same number thought that winSee Table I. A total of 675 surveys were mailed and dow tinting was protective from sun damage 225 surveys were received with a median patient age whereas 10% did not know either way (Table III). of 68 years and a gender distribution of 56% female Regardless of the frequency of application, the and 44% male. Patients were mainly fair skinned: head and neck was by far the most common 89% were of skin types I, II, or III. Of responders, location for sunscreen application. Notably, 32% 90% had a history of at least 1 type of skin cancer. of patients who reported wearing sunscreen most Thirty patients had a malignant melanoma (MM), 102 of the time while in a vehicle did not apply it to patients presented with at least 1 NMSC, and 12 their hands and arms (Table IV). Significant positive patients had both MM and NMSC. Male respondents predictors of sunscreen use while in an automobile drove more than female respondents (median 10 vs 5 were female gender and family history of melah/wk, and 50 vs 43 years, both P \ .05). When in an noma. Significant positive predictors of general automobile, respondents were usually the driver and daily sunscreen use were female gender, age youndrove mostly during the daytime. ger than 50 years, lighter skin type, participating in outdoor recreation, and a family history of skin Patients perception of automobile-related sun cancer. exposure and need for sunscreen application A majority of respondents did not think they needed to use sunscreen while driving with the Laterality of skin cancer development windows closed or open. However, a personal NMSC occurred more on the left, the same side as history of skin cancer was associated with an inthe drivers seat in the United States, whereas melcreased perceived need for sunscreen while in a anomas occurred more on the right (Tables V and vehicle. For example, 53.4% of patients with a VI). Patients with right-sided NMSC were more likely personal history of skin cancer believed they needed to have tinted windows relative to patients with leftto wear sunscreen while driving with the windows sided NMSC (86% vs 39%, P \ .01). Conversely, open in contrast to only 18.2% without a history of patients who never had tinted windows had more skin cancer (P \ .01) (Table II). A majority of left-sided NMSC (86% vs 42%, P \ .05).
d d d

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Table I. Characteristics of 225 patient respondents


Age, y, mean 6 SD Skin Fitzpatrick phototype I II III IV V-VI Gender M F Medical history of skin cancer No. of lesions: 0 1 At least 2 Type of lesion: Squamous cell carcinoma Basal cell carcinoma Melanoma Benign lesion Recreational activity Mostly indoors About equally indoors and outdoors Mostly outdoors Median No. of hours spent in vehicle in typical week When you are in motor vehicle are you More often the driver More often the passenger About equal During typical week do you drive Mostly at night About equal day/night Mostly during day 67.5 6 17 % n 11 42 36 8 3 56 44 25 93 79 17 6 126 99

Table II. Patient perception of automobile-related sun exposure and need for sunscreen application
a. Do you think you need to use sunscreen while driving with windows: Closed? % n % Open? n

Yes No

33 67

70 145

49 51

105 110

b. Do you think you are protected from sun damage to your skin when driving with windows: Closed? % n % Open? n

11 52 37 12 40 15 \1 24 34 42

24 117 82 23 79 30 1 53 76 95 7

Yes No

40 60

87 130

14 86

30 184

c. (Of 87 respondents who thought they were protected with windows closed) Do you believe you need to use sunscreen while driving with windows: Closed? % n % Open? n

Yes No

12 88

10 76

41 59

35 50

d. (Of 130 respondents who did not think they were protected with windows closed) Do you believe you need to use sunscreen while driving with windows: Closed? % n % Open? n

86 8 6 0 9 91

192 18 14 0 19 199

Yes No

46 54

59 68

54 46

68 59

e. Do you believe that tinted windows help protect your skin from damage? % n

Proportions do not add to total for all characteristics because of missing data (ie, nonresponse) for that characteristic. F, Female; M, male.

Yes No Did not know

53 37 10

115 79 21

DISCUSSION
Our results reveal poor patient awareness of the need for sun protection while in an automobile. Most respondents were aware that sun exposure while driving, even with windows closed, can damage the skin; however, few regularly used sunscreen while in an automobile. Those who believed they were protected by closed windows were even less likely to appreciate the need for sunscreen. Importantly, these data indicate an inconsistency between beliefs and actions. Although a personal history of skin cancer was associated with an increased perceived need for sunscreen while in an automobile, this highrisk population did not use sunscreen any more frequently than those without a personal history of

skin cancer. Furthermore, our results show that responding yes to sunscreen surveys does not ensure appropriate coverage. Thus, given the large amount of automobile-related sun exposure over a lifetime, and the poor awareness of the need for sunscreen in this setting, it is important to emphasize that patients should use sunscreen while driving, even when their windows are closed. Automobile glass and photoprotection The major factors governing the transmission of UV radiation (UVR) through automobile glass are the type of glass, degree of tinting, and presence or absence of lamination or UV-absorbing lm.5 According to one study, clear glass transmitted 62%

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Table III. Use of sun-protection measures


a. Do you use sunscreen daily? Most of the time About half the time Less than half the time b. When you are in vehicle, would you say that you are wearing sunscreen: Most of the time About half the time Less than half the time c. When you are in vehicle, would you say that you are wearing sunscreen: (Only respondents with history of skin cancer, n = 199) Most of the time About half the time Less than half the time d. Have you or anyone in your household ever had vehicle with tinted windows? Yes No e. Does vehicle you currently drive or are passenger in have tinted windows? Yes No Did not report or know f. When weather permits, how often do you drive with window nearest you open? More than half the time About half the time Less than half the time % 38 15 48 n 84 33 107

in-built UVR protective measures in automobile windows may be a more effective sun-protection strategy. Clinical signicance of UV exposure in automobiles Our study corroborates previously reported ndings that NMSC occur more on the left. We also report a protective effect conferred by a history of window tinting on NMSC. A number of studies have attributed an asymmetric distribution of cutaneous disease to UV exposure through windows.8,9 However, the association between laterality of MM development and UVR exposure while in a vehicle is controversial. Given that UVA has been implicated in melanoma development, and prior studies have shown leftsided predominance, it is not clear why we found more melanomas on the right side of the body.10,11 The laterality of cancer development, especially melanoma, is likely multifactorial. For instance, previous studies have found a left-sided predominance even in countries where the drivers seat is on the right side of the car.10 Finally, additional factors, such as variable spatial distribution of transcription factors during embryologic development, may contribute to the laterality of MM development.12,13 Limitations One limitation of this study is the sample size, which hampers conclusions about laterality, and limits the ability to identify differences between subgroups. Selection bias is another possible limitation because most of the participants had a personal history of skin cancer. Because the average patient age in this survey was 67.5 years, the results may also suffer from age and generational bias. It has been previously shown that older adults are more compliant with sun-protection measures; hence, sunscreen use in the overall population may have been overestimated.14 In contrast, a generational bias arising from increased contemporary awareness of sun exposureerelated carcinogenicity would counter age-related overestimation of sunscreen use. As the questionnaire in the study was selfadministered, participants may have answered in a socially desired way, overestimating their sunrelated awareness and behavior, even though the study was conducted anonymously to bolster truthfulness. Potential social desirability bias is inherent to a retrospective survey of this kind, and detailed prospective diary recordings could lessen this in future studies.15 Finally, recall bias likely played an influential role given the difficulty in recollecting ones driving behavior, automobile ownership, site of skin cancer, and sunscreen use.

15 11 73

34 25 163

16 12 73

31 23 143

53 47

118 104

44 8 48

99 17 109

26 19 55

57 43 123

of UVA whereas dark-tinted glass transmitted only 11.4%. This correlates with our clinical data, as the only factor showing statistical significance with respect to NMSC laterality was tinting. Parisi and Wong6 illustrated that the shoulder, arm, and hand closest to the side window receive the highest UV exposure. This is because windshields are made from laminated glass that allows only 2% transmission of UVA. In contrast, side and rear windows are usually nonlaminated and transmit upward of 80% of UVA.7 Our data show that in addition to the low rates of sunscreen use, when sunscreen is applied, it is frequently not applied to these high-exposure areas. Windows with UV-absorbing lms provide the greatest protection against UVR. These lms allow only 0.4% transmission of UVR with concomitant reductions in cell toxicity in in vitro studies.5,7 UVabsorbing films have the added benefit of being clearer than window tinting, and therefore allow for greater visibility while simultaneously reducing exposure to harmful UVR. Given the dismal rates of sunscreen use while in an automobile, promotion of

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Table IV. Location of sunscreen application


Head and neck Hand and arm Chest Abdomen Back Leg Feet

Daily sunscreen use Most of the time Half the time Less than half the time Sunscreen use while in vehicle Most of the time Half the time Less than half the time

96% 97% 79% 100% 100% 85%

77% 81% 63% 68% 83% 71%

38% 0% 26% 38% 0% 33%

15% 16% 17% 12% 0% 19%

32% 28% 27% 32% 0% 32%

50% 38% 45% 47% 6% 49%

31% 25% 19% 38% 6% 23%

Table V. Patients self-reported anatomic locations for malignant melanoma and nonmelanoma skin cancers
No. of patients MM Anatomic location Left Right NMSC Left Right MM Total NMSC

3.

4.

Head and neck Arm Back or chest Leg Total

2 3 3

15 2 1 18

2 5 0 3 10

23 2 0 1 26

5.

6.

MM, Malignant melanoma; NMSC, nonmelanoma skin cancer.

7.

Table VI. Laterality of skin cancer development


Left Right P

8.

NMSC MM

62% 20%

28% 80%

\.03 \.03

9.

MM, Malignant melanoma; NMSC, nonmelanoma skin cancer.

CONCLUSION
Most patients do not think they need to use sunscreen while driving. A history of skin cancer increases the perceived need to use sunscreen while in a vehicle. However, despite this increased awareness, sunscreen use while in a vehicle remains suboptimal among all patients. Further supporting the impact of automobile-related UV exposure, this study conrmed a predominance of left-sided NMSC.16-19 Highlighting its utility, and alluding to the putative role of UVA in skin carcinogenesis, window tinting correlated with a decrease in leftsided NMSC.
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