{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T08:52:30Z","timestamp":1791967950048,"version":"4.3.4"},"update-to":[{"DOI":"10.3310\/nihropenres.13980.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T00:00:00Z","timestamp":1764288000000}}],"reference-count":108,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T00:00:00Z","timestamp":1764288000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100009129","name":"Evidence Synthesis Programme","doi-asserted-by":"publisher","award":["NIHR161983"],"award-info":[{"award-number":["NIHR161983"]}],"id":[{"id":"10.13039\/501100009129","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["openresearch.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["NIHR Open Res"],"abstract":"<ns3:p>Introduction Current sun safety advice focuses on minimizing exposure to sunlight, due to the relationship between ultraviolet radiation and skin cancer. However, sunlight also has beneficial effects, and there are calls for guidance to reflect these alongside the harmful effects. To examine the net effect of harmful and beneficial aspects, we aimed to determine the association between sunlight exposure and all-cause mortality. Additionally, we examined cause-specific mortality and whether the associations varied according to skin type\/colour or ethnicity. Methods We conducted a systematic review, searching MEDLINE, Embase, Web of Science and the Cochrane Central Register of Controlled Trials (Nov 2023) for reports of epidemiological studies in the general population investigating the effect of long-term sun exposure on all-cause, cardiovascular-related, or cancer-related mortality. We conducted a narrative synthesis of the findings and assessed risk of bias using the ROBINS-E tool. PROSPERO: CRD42023474157. Results The search identified 73 eligible articles, with 55 included in the narrative synthesis. Methods of measuring sunlight exposure comprised radiation, proxy measures of radiation (e.g., latitude) and behaviour associated with sunlight exposure. The evidence was mixed. While most studies of skin cancer mortality found a higher risk associated with more exposure to sunlight, many studies of other cancers reported lower associated risk. Evidence for all-cause mortality was mixed, as were findings for cardiovascular mortality. Results were subject to high risk of bias, largely due to the likelihood of uncontrolled confounding and the use of indirect measures of sunlight exposure. There were insufficient data regarding any differential effects of sunlight on mortality for those of different skin types\/colours or ethnicity. Conclusion Findings from observational epidemiological studies of the association between sunlight exposure and mortality vary across different disease outcome and location being investigated. As such, the findings do not provide a strong rationale for changes to sun protection guidance.<\/ns3:p>","DOI":"10.3310\/nihropenres.13980.2","type":"journal-article","created":{"date-parts":[[2025,11,28]],"date-time":"2025-11-28T18:05:08Z","timestamp":1764353108000},"page":"51","update-policy":"https:\/\/doi.org\/10.3310\/nihropenres.crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["The effects of sunlight exposure on mortality: a systematic review of epidemiological studies"],"prefix":"10.3310","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6773-5376","authenticated-orcid":false,"given":"Thomas","family":"Parkhouse","sequence":"first","affiliation":[{"name":"NIHR Bristol Evidence Synthesis Group, Population Health Sciences, Bristol Medical School Bristol England BS8 2PS University of Bristol"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca","family":"Spiga","sequence":"additional","affiliation":[{"name":"NIHR Bristol Evidence Synthesis Group, Population Health Sciences, Bristol Medical School Bristol England BS8 2PS University of Bristol"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lesley E","family":"Rhodes","sequence":"additional","affiliation":[{"name":"Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, NIHR Manchester Biomedical Research Centre Manchester England M13 9PL The University of Manchester"},{"name":"Dermatology Research Centre, Salford Royal Hospital, Manchester Academic Health Science Centre Salford England Northern Care Alliance NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Dawson","sequence":"additional","affiliation":[{"name":"NIHR Bristol Evidence Synthesis Group, Population Health Sciences, Bristol Medical School Bristol England BS8 2PS University of Bristol"},{"name":"NIHR Applied Research Collaboration West (ARC West) Bristol England University Hospitals Bristol and Weston NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-7997-4133","authenticated-orcid":false,"given":"Katie E","family":"Webster","sequence":"additional","affiliation":[{"name":"NIHR Bristol Evidence Synthesis Group, Population Health Sciences, Bristol Medical School Bristol England BS8 2PS University of Bristol"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8014-7480","authenticated-orcid":false,"given":"Deborah M","family":"Caldwell","sequence":"additional","affiliation":[{"name":"NIHR Bristol Evidence Synthesis Group, Population Health Sciences, Bristol Medical School Bristol England BS8 2PS University of Bristol"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian P T","family":"Higgins","sequence":"additional","affiliation":[{"name":"NIHR Bristol Evidence Synthesis Group, Population Health Sciences, Bristol Medical School Bristol England BS8 2PS University of Bristol"},{"name":"NIHR Applied Research Collaboration West (ARC West) Bristol England University Hospitals Bristol and Weston NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2025,11,28]]},"reference":[{"key":"ref-1","article-title":"Sun safety.","year":"2021"},{"key":"ref-2","article-title":"Sunscreen and sun safety.","year":"2022"},{"key":"ref-3","article-title":"Sunlight exposure: risks and benefits (NG34).","year":"2016"},{"key":"ref-4","article-title":"Sunlight","year":"2023"},{"key":"ref-5","article-title":"A review of human carcinogens. 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Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T08:29:16Z","timestamp":1791966556000},"score":1,"resource":{"primary":{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,28]]},"references-count":108,"URL":"https:\/\/doi.org\/10.3310\/nihropenres.13980.2","relation":{"has-version":[{"id-type":"doi","id":"10.3310\/nihropenres.13980.1","asserted-by":"subject"}],"has-review":[{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38570","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38572","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38574","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38571","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38575","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38570","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38572","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38571","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38574","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15427.r38575","asserted-by":"object"}]},"ISSN":["2633-4402"],"issn-type":[{"value":"2633-4402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,28]]},"assertion":[{"value":"Indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.3310\/nihropenres.15427.r38574, Richard Weller, University of Edinburgh, Edinburgh, 30 Dec 2025, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-response-38574","order":0,"name":"referee-response-38574","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15427.r38575, Rasha Shraim, Trinity College Dublin, Dublin, 30 Dec 2025, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-response-38575","order":1,"name":"referee-response-38575","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15427.r38571, Leonardo Vin\u00edcius Monteiro de Assis, Chemistry and Molecular Biology, University of Gothenburg, Gothenburg, V\u00e4stra G\u00f6taland County, 06 Jan 2026, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-response-38571","order":2,"name":"referee-response-38571","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15427.r38570, Douglas Brash, Yale School of Medicine, New Haven, 08 Jan 2026, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-response-38570","order":3,"name":"referee-response-38570","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Tom Parkhouse<\/b>; \n<i>Posted: 08 Jan 2026<\/i>; Dear Dr. Brash,  Many thanks again for reviewing our paper and providing such helpful feedback.  Regarding the figures - when the second version was initially published there was an issue where they had included the original figures instead of the updated ones. I quickly made the journal aware of this and they corrected the error within a day or so. Did you possibly download the new version during this window (it would have been late November)? If not, and you are still seeing the original figures on Version 2, I would be very grateful if you would let me know so that I can make the journal aware that this is an ongoing issue.","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-comment-3527","order":4,"name":"referee-comment-3527","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15197.r36115, Carolyn Heckman, Rutgers Cancer Institute, New Brunswick, 30 Aug 2025, version 1, 4 approved with reservations, 2 not approved","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v1#referee-response-36115","order":5,"name":"referee-response-36115","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Tom Parkhouse<\/b>; \n<i>Posted: 08 Dec 2025<\/i>; Many thanks for this thorough, helpful review of our paper. We have attempted to address your points and respond to each below.  \n<b>Title - Seeing the variety of types of exposures, I\u2019m wondering whether \u201csunlight exposure\u201d is the most appropriate term. You could also add something about the international sample.<\/b> \n<b>Response: <\/b>We understand your point, though as sunlight exposure was the underlying effect we were interested in, and we have defined what this term encompasses, we feel that this is an appropriate title.  \n<b>Abst - Based on the Results, I suggest changing the final number of the articles in the Abstract and Figure 1 to 55.<\/b> \n<b>Response: <\/b>Thank you. We have amended both the abstract and Fig 1 to make it clear that 55 articles were included in the narrative synthesis.  \n<b>Lay Summary 1. Could be clarified. The first two sentences make it seem that burns rather than UV exposure cause all skin cancers.<\/b> \n<b>Response: <\/b>We have edited this sentence to make it more about UV exposure, whilst keeping it appropriate for a PLS: \u201cSunlight exposure of the skin can lead to the development of skin cancer\u201d  \n<b>2. Sunscreen is not mentioned.<\/b> \n<b>Response: <\/b>We have now included sunscreen: \u201cOrganizations providing advice on sun exposure say to wear sunscreen and covering clothing, and to stay in the shade between 11am and 3pm.\u201d  \n<b>3. I think something along the lines of \u201climits of available data\u201d would be more accurate than \u201cproblems in how the studies were done.\u201d<\/b> \n<b>Response: <\/b>We feel that limits of available data is a slightly different issue to the one we were referring to here (essentially RoB concerns). However, we have changed the wording to include the issue of data availability and to hopefully clarify the point: \u201cHowever, there were issues with the amount of data available, as well as the quality of some of the data that was available\u2026\u201d  \n<b>4. A reminder at the end about sun protection would seem appropriate.<\/b> \n<b>Response: <\/b>We have added to the final sentence to include this: \u201cCurrently, there is not strong enough evidence to alter sun exposure advice and so people should continue to follow the guidance.\u201d  \n<b>Intro 1. Recommendations from the US National Cancer Institute might be more comparable to the other sources you note as opposed to the AAD.<\/b> \n<b>Response: <\/b>Thank you. We have changed this reference from the AAD to the NCI.  \n<b>2. I would include something about sunburns in childhood increasing risk for BCC too.<\/b> \n<b>Response: <\/b>We have added the statistic about childhood sunburns from the same review: \u201cthe risk of developing basal cell carcinoma (BCC), the most common form of non-melanoma skin cancer (NMSC), is 1.86 and 2.12 times greater with every five sunburns experienced as a child and as an adult, respectively\u201d  \n<b>Methods 1. If no randomized trials were included, I would not mention that design. If they were, please report something about them, specifically.<\/b> \n<b>Response: <\/b>No RCTs were included but we did search for them. We feel it is important to highlight that our search terms included RCTs, even if we failed to find any that met the inclusion criteria. Therefore, in the section of the results discussing the characteristics of the included studies, we have added the sentence \u201cWe did not identify any eligible randomized controlled trials.\u201d  \n<b>2. Summarize the bias criteria.<\/b> \n<b>Response: <\/b>We have provided some more information regarding the domains assessed with ROBINS-E: \u201cROBINS-E is a tool designed to evaluate the risk of bias in results of observational epidemiologic studies, covering aspects of design, conduct and reporting of the study. It assesses risk of bias across seven domains: confounding, measurement of the exposure, selection of participants, post-exposure interventions, missing data, measurement of the outcome and selection of the reported result.\u201d  \n<b>3. Briefly describe the GRADE domains.<\/b> \n<b>Response: <\/b>We have provided a brief description of the five GRADE domains: \u201cThe GRADE domains assess the risk of bias in the included studies (risk of bias); how consistent the results are within each outcome (inconsistency); how applicable the evidence is to the review question (indirectness); how precise the estimates are (imprecision); and the possibility of selective publication of results (publication bias).\u201d  \n<b>4. For studies that didn\u2019t report race or ethnicity: Would it be appropriate to consider the race and ethnic composition of some of the study countries during the time(s) of data collection? E.g., studies conducted in China likely included mostly Asian participants. Or to consider findings for whites vs. non-whites, though admittedly less than ideal.<\/b> \n<b>Response: <\/b>Unfortunately, there was a lack of reporting of individual data regarding skin type\/colour or ethnicity across the population level studies. Whilst we could use separate demographic information for countries\/regions at the time of the study to infer race\/ethnicity for some of the ecological studies, this is unfortunately beyond the scope of the current review and may not always be appropriate to perform as it would require broad assumptions. It also wouldn\u2019t give us individual data, and therefore would not be appropriate to apply to case-control and cohort studies.  \n<b>5. Would it be appropriate to weight the findings based on sample size, level of bias, null findings, and\/or something else?<\/b> \n<b>Response: <\/b>As there is no statistical synthesis, any weighting would be challenging. However, we have added the number of participants included in the full cohort for all cohort studies with results for the primary outcomes in order to assist in interpretation. Where reported, we have also added the number of deaths among the cohort (relevant to each outcome). Sample sizes and considerations of power are less relevant to interpretation than are confidence intervals around estimated effect sizes, and we report these wherever they were available to us. We do not elaborate substantially on sample size differences, since in observational studies, larger is not necessarily better (as discussed, for example, by Egger et al (\u201cSpurious precision? Meta-analysis of observational studies\u201d. BMJ 1998; 316; https:\/\/doi.org\/10.1136\/bmj.316.7125.140).  \n<b>Results p.12&nbsp; - right paragraph \u2013 There seems to be an error in the reporting of the direction of the relationships.<\/b> \n<b>Response: <\/b>We agree, this reporting was incorrect (and confusingly worded) \u2013 thank you for pointing this out. The text has now been corrected and hopefully the wording is clearer: \u201ctwo found a positive relationship between degree of latitude and melanoma mortality, suggesting that those living at more northerly latitudes, where there is less sunlight, experienced higher levels of melanoma mortality.\u201d  \n<b>Discussion 1. There seem to be contradictory statements in the first paragraph.<\/b> \n<b>Response: <\/b>We have adapted the first sentence so that it now reads \u201ca mixed message about the association between sunlight exposure and \n<b>all-cause<\/b> mortality risk.\u201d  \n<b>2. The US population of Native Americans is quite small, and reporting for that group is notoriously poor. Those findings should be considered with caution.<\/b> \n<b>Response: <\/b>We have added a note of caution to this result: \u201cAlthough this result should be treated with caution as the Native American population is relatively small.\u201d  \n<b>3. Expand on the bias issues. What are the major confounders? One would be physical activity. Assuming that was considered in some studies, it might be worth including as an additional reporting variable.<\/b> \n<b>Response: <\/b>We have added a paragraph in the results regarding important confounders, with a brief overview of the most\/least common factors controlled for: \u201cThe majority of results that were assessed for risk of bias were judged to be of some concern or high risk of bias. There were no results we judged to be low risk of bias across all domains, whilst some were assessed to be at very high risk of bias. The most common reasons for potential bias were uncontrolled confounding and concerns over the measurement of exposure. Concerns in the latter of these focused on the lack of direct measurement of personal sunlight&nbsp; exposure, as is largely inevitable in large population-based studies, as well as the use of aggregated measures that may have misclassified individual exposure. In order to judge the risk of bias due to confounding, we prespecified a number of important confounding factors which should have ideally been controlled for, including age, sex\/gender, ethnicity, smoking status, socioeconomic status, physical activity and altitude. No study included in the review controlled for all of these factors. The most commonly controlled for factors were age and sex\/gender, followed by smoking. Looking at the primary outcomes, around half of the results controlled for race\/ethnicity, though this was predominately achieved through restricting analysis to White participants. Physical activity was less well controlled for, whilst almost no studies controlled for altitude.\u201d  We have also added a paragraph in the discussion, addressing the difficulty in disentangling the effects of sunlight on the skin from confounders and lifestyle factors: \u201cFurthermore, the fact that no study was conducted using a direct measurement of individual sunlight exposure makes it difficult to disentangle the specific effects of sunlight on the skin from various potential confounders. For example, it is feasible that people living in areas with higher levels of sunlight experience health benefits such as increased outdoor physical activity, better diet, and improved quality of life. Moreover, the effect of such confounders are likely to vary across region and\/or country, further complicating the relationship.\u201d  \n<b>4. The review separated studies by measure of UV, but as mentioned, risk is determined by available UV (e.g., latitude) and exposure to UV (e.g., behavior). Can these types of measures be combined somehow for studies in a similar\/same place\/time?<\/b> \n<b>Response: <\/b>Although this would be an interesting extension to the findings, unfortunately there is insufficient individual data available to do this currently.  \n<b>5. Wondering if it would be useful to include the tables\/figures on specific cancers (other than skin) as supplements?<\/b> \n<b>Response: <\/b>NIHR Open requires all information that is necessary to follow the methods and results of the review to be included in the paper. Therefore, we are unable to send these to the supplement.  \n<b>6. It would seem that the pancreatic cancer findings could be emphasized since they were mostly consistent.<\/b> \n<b>Response: <\/b>We have now added a sentence in the discussion to highlight the pancreatic cancer results: \u201cIn contrast, most articles examining the five cancers with the highest UK mortality rate (breast, prostate, lung, bowel and pancreatic cancer) found that higher levels of sunlight were associated with lower risks of mortality. In particular, for pancreatic cancer, where the available evidence was somewhat consistent in suggesting a beneficial effect of sunlight.\u201d  \n<b>7. The recent guidelines by Australians regarding tailored recommendations should be discussed in the Intro and\/or Discussion and why those may be valid or not as compared to the current review.<\/b> \n<b>Response: <\/b>We have added reference to this guidance in the discussion, in relation to the paragraph addressing the lack of available evidence on skin type\/race and the need for more tailored guidance: \u201cSkin cancer mortality was the only outcome for which the evidence clearly suggested that the risks of sunlight exposure outweighed the benefits. Given that melanoma mortality is known to be lower in those with darker skin (Lopes, et al, 2021), this highlights the need for nuanced sun exposure guidance. However, approximately a quarter of the main articles included in this review were restricted to White populations. Around two thirds reported on the whole population, though given that a large number of these were conducted in Europe and North America, it is likely that the populations in those articles were predominantly White as well. In order to gain a more complete picture of the relationship between sunlight exposure and mortality, further studies investigating the impact of skin type\/colour or ethnicity are warranted. This, in turn, would help organizations responsible for sun safety messaging to provide more appropriate guidance for those with different skin types. For example, a recent summit of sun exposure experts in Australia promoted the use of sun safety advice that clearly distinguishes recommendations for people of different skin types (Neale et al, 2004).\u201d","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-comment-3519","order":6,"name":"referee-comment-3519","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15427.r38572, Richard McKenzie, Ben Liley, James Liley, National Institute of Water and Atmospheric Research Lauder Atmospheric Research Station (Ringgold ID: 563277), Lauder, Otago, 16 Dec 2025, version 2, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/5-51\/v2#referee-response-38572","order":7,"name":"referee-response-38572","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This project was funded by the National Institute for Health and Care Research (NIHR) under its Evidence Synthesis Programme (grant reference number: NIHR161983). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":8,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}