We are Just Realizing Nobody Understands Sunscreen

by Justin Q Taylor

We are in an age of extreme failures of public health communication. Our society is realizing that we don’t know how, or even when, to communicate public health messages. In an era that sees politicians pandering to vaccine deniers,  nutrition research finding butter health-neutral, and myriad other public health crises, it is hard to know what to focus on. Some things, however are easy wins. As The Atlantic’s James Hamblin points out today, proper use of sunscreen might be the easiest cancer prevention tool. But public health officials have dropped the ball, and it has been up to journalists like Hamblin and Vox.com’s sunscreen crusader Julia Belluz to explain sun damage to the world.

Hamblin’s piece points to a JAMA survey about sunscreen knowledge. Some questions may have been confusingly worded, but only 23% of respondents completely understood that SPF is a measure of protection against sunburn. Hamblin goes on to point out the remarkable fact that the American Academy of Dermatology (AAD) and the FDA manage to disagree on what the letters SPF stand for. AAD calls it “Sun Protection Factor,” and the FDA calls it “Sunburn Protection Factor.”

Hamblin leaves it at that, but it seemed worth delving in to the origin of this discrepancy. It turns out, this difference is due to a rule change in 2007. Here is the FDA’s (vague) justification:

Several comments recommended changing the acronym ‘‘SPF’’ from ‘‘sun protection factor’’ to ‘‘sunburn protection factor’’ because the 33 latter definition is more descriptive of the use of OTC sunscreen drug products and avoids giving consumers the impression of solar invincibility and a false sense of security. FDA agrees. In § 352.52(b) of the sunscreen FM, FDA included only indications for sunburn protection (e.g., ‘‘helps prevent sunburn’’) (64 FR 27666 at 27691). In this document, FDA is proposing to change the word ‘‘sun’’ to ‘‘sunburn’’ in § 352.3(b)(1), (b)(2), (b)(3), and (d) and § 352.52(e)(1)(i), (e)(1)(ii), and (e)(1)(iii).

On the AAD website, it is also explicitly stated that “Currently, there is not any scientific evidence that indicates using a sunscreen with an SPF higher than 50 can protect you better than a sunscreen with an SPF of 50.” Hamblin points out that a 2011 Procter & Gamble study even called for an end to higher ratings, calling them misleading. This translated to a 2011 proposed regulation by the FDA which would make “SPF 50+” the highest allowable claim on packaging, but it does not seem to have gone anywhere since. Notably, the description of this proposed rule change defines SPF as “Sun Protection Factor,” despite being published 4 years after the FDA’s change to “Sunburn Protection.”

The confusion within the FDA over simple terminology is an indication of how well they are able to communicate about sun protection to the public. As in the quote above, the FDA continuously adopts a paternalistic tone in response to proposed simplifications of labeling requirements, insisting that they would make it harder for consumers to understand the products. It is clear, however, that consumers don’t understand the current system. It is likely that SPF, a numbered system with no intuitive association linking the numbers to expected results, should be replaced with another measurement. The FDA, however, is resistant to this idea as well:

Consumers have relied on SPF values for over 30 years and are familiar with this format. Therefore, expressing SPF values as percentages may be confusing. It would imply that the stated percentage of the entire UV spectrum is absorbed by a sunscreen. However, the SPF values only reflect protection against the portion of the UV spectrum that causes sunburn. Additionally, the percentages of UV radiation screened that the submission notes are theoretical.

if SPF values were expressed as percentages, consumers might mistakenly believe that the sunscreen products they are using provide more protection than they really do provide under actual use conditions.

While it’s clear that the percentage proposal would have to be more specific about what the percentage expressed, the FDA’s rebuttal is weak. It is particularly egregious to cite consumers’ familiarity with the current system. It seems the current SPF system is confusing to everyone, even the FDA.

In public health circles, education is regarded as the key to prevention. This usually manifests itself as some form of public outreach. There is no doubt that the public needs to be better educated about sun protection, but changing the SPF system might be the best way to help confused consumers. No method of educating consumers will allow them to make intuitive decisions about sunscreen until there is a labeling system that makes sense.