# Are people more concerned about photoaging than skin cancer when raising awareness about risks of skin exposure?

Brigitte Dreno, Thierry Passeron, Susana Puig, Henry Lim, Chee Leok Goh, Hee Young Kang, Fatimata Ly, Akimichi Morita, Jorge Ocampo-Candiani, Sergio Schalka, et al.

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## To cite this version:

Brigitte Dreno, Thierry Passeron, Susana Puig, Henry Lim, Chee Leok Goh, et al.. Are people more concerned about photoaging than skin cancer when raising awareness about risks of skin exposure?. Clinical and Experimental Dermatology, 2024, pp.11-22. 10.1093/ced/llae225. inserm-04603526

HAL Id: inserm-04603526

https://inserm.hal.science/inserm-04603526

Submitted on 6 Jun 2024

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1 Are people more concerned about photoaging than skin cancer when raising awareness about risks of skin exposure?

2 Running head: Fear photoaging vs skin cancer

3
4
5 Brigitte Dreno,¹ Thierry Passeron,²,³ Susana Puig,⁴ Henry W. Lim,⁵ Chee Leok Goh,⁶
6 Hee Young Kang,⁷ Fatimata Ly,⁸ Akimichi Morita,⁹ Jorge Ocampo-Candiani,¹⁰ Sergio
7 Schalka,¹¹ Liu Wei,¹² Anne Laure Demessant,¹³ Caroline Le Floc'h,¹³ Delphine Kerob¹³
8 and Jean Krutmann¹⁴

9
10 1. Nantes University, Univ Angers, INSERM, Immunology and New Concepts in ImmunoTherapy, INCIT, UMR 1302, Nantes, France

12 2. Department of Dermatology, Côte d'Azur University, Nice University Hospital Center, Nice, France

14 3. INSERM U1065, C3M, Côte d'Azur University, Nice, France

15 4. Dermatology Department, Hospital Clinic de Barcelona, Barcelona University, Barcelona,Spain

17 5. Department of Dermatology, Henry Ford Health, Detroit, MI, USA

18 6. National Skin Centre, Singapore, Singapore

19 7. Department of Dermatology, Ajou University School of Medicine, Suwon, South Korea

20 8. Department of Dermatology, Cheikh Anta Diop Dakar University, EPS Institute of Social Hygiene, Dakar, Senegal

22 9. Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan

24 10. Department of Dermatology, Medical Faculty University Hospital of Nuevo Leon, Monterrey, Mexico

26 11. Medecin Skin Research Center and Biochemistry Department, Chemistry Institute of Sao Paulo University, Sao Paulo, Brazil

28 12. Department of Dermatology, The General Hospital of Air Force PLA, Beijing, China
1 Are people more concerned about photoaging than skin cancer when raising awareness about risks of skin exposure?

2 Running head: Fear photoaging vs skin cancer

3
4
5 Brigitte Dreno,¹ Thierry Passeron,²,³ Susana Puig,⁴ Henry W. Lim,⁵ Chee Leok Goh,⁶
6 Hee Young Kang,⁷ Fatimata Ly,⁸ Akimichi Morita,⁹ Jorge Ocampo-Candiani,¹⁰ Sergio
7 Schalka,¹¹ Liu Wei,¹² Anne Laure Demessant,¹³ Caroline Le Floc'h,¹³ Delphine Kerob¹³
8 and Jean Krutmann¹⁴

9
10 1. Nantes University, Univ Angers, INSERM, Immunology and New Concepts in ImmunoTherapy, INCIT, UMR 1302, Nantes, France

12 2. Department of Dermatology, Côte d'Azur University, Nice University Hospital Center, Nice, France

14 3. INSERM U1065, C3M, Côte d'Azur University, Nice, France

15 4. Dermatology Department, Hospital Clinic de Barcelona, Barcelona University, Barcelona,Spain

17 5. Department of Dermatology, Henry Ford Health, Detroit, MI, USA

18 6. National Skin Centre, Singapore, Singapore

19 7. Department of Dermatology, Ajou University School of Medicine, Suwon, South Korea

20 8. Department of Dermatology, Cheikh Anta Diop Dakar University, EPS Institute of Social Hygiene, Dakar, Senegal

22 9. Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan

24 10. Department of Dermatology, Medical Faculty University Hospital of Nuevo Leon, Monterrey, Mexico

26 11. Medecin Skin Research Center and Biochemistry Department, Chemistry Institute of Sao Paulo University, Sao Paulo, Brazil

28 12. Department of Dermatology, The General Hospital of Air Force PLA, Beijing, China
1 13. La Roche-Posay International, Levallois-Perret, France

2 14. IUF Leibniz Research Institute for Environmental Medicine, Duesseldorf, Germany,

3

4 **Corresponding author:** Anne Laure Demessant

5 **Email:** anne-laure.demessant@loreal.com

6

7 **Funding sources:** As part of the HELIOS project, this work was funded by La Roche-

8 Posay Laboratoire Dermatologique, France

9 **Conflict of interest:** **Pr Passeron** reports personal fees from La Roche Posay during the conduct of the study and personal fees from L'Oréal. **Pr. Lim** is an investigator for L'Oreal, has served as a consultant for La Roche-Posay, and has been a speaker on general educational session for La Roche-Posay. **Pr. Goh** reports other support from La Roche Posay during the conduct of the study. **Pr. Kang** reports personal fees from L'Oréal during the conduct of the study. **Pr. Ly** has nothing to disclose. **Pr. Morita** reports personal fees from L'Oréal during the conduct of the study. **Dr. Ocampo-Candiani** reports personal fees from La Roche Posay during the conduct of the study. **Pr. Puig** reports personal fees from La Roche Posay, during the conduct of the study and personal fees and non-financial support from La Roche Posay. **Dr. Schalka** has served as a consultant for La Roche Posay and has participated as a speaker in an educational session for La Roche-Posay.

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20 **Pr. Wei** reports personal fees from La Roche Posay during the conduct of the study. **A.-L. Demessant-Flavigny**, **C. Le Floc'h**, **Dr D. Kerob** are employees of La Roche Posay.

21

22 **Pr. Dreno** reports personal fees from La Roche Posay International during the conduct of the study. **Pr. Krutmann** reports personal fees from La Roche Posay during the conduct of the study and grants and personal fees from L'Oréal.

23

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25 **Data availability:** The data that support the findings of this study are available from the corresponding author upon reasonable request.

26

27 **Ethics statement:** This survey was conducted has been carried out according to the ICC/ESOMAR code of conduct.

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1 13. La Roche-Posay International, Levallois-Perret, France

2 14. IUF Leibniz Research Institute for Environmental Medicine, Duesseldorf, Germany,

3

4 **Corresponding author:** Anne Laure Demessant

5 **Email:** anne-laure.demessant@loreal.com

6

7 **Funding sources:** As part of the HELIOS project, this work was funded by La Roche-

8 Posay Laboratoire Dermatologique, France

9 **Conflict of interest:** **Pr Passeron** reports personal fees from La Roche Posay during the conduct of the study and personal fees from L'Oréal. **Pr. Lim** is an investigator for L'Oreal, has served as a consultant for La Roche-Posay, and has been a speaker on general educational session for La Roche-Posay. **Pr. Goh** reports other support from La Roche Posay during the conduct of the study. **Pr. Kang** reports personal fees from L'Oréal during the conduct of the study. **Pr. Ly** has nothing to disclose. **Pr. Morita** reports personal fees from L'Oréal during the conduct of the study. **Dr. Ocampo-Candiani** reports personal fees from La Roche Posay during the conduct of the study. **Pr. Puig** reports personal fees from La Roche Posay, during the conduct of the study and personal fees and non-financial support from La Roche Posay. **Dr. Schalka** has served as a consultant for La Roche Posay and has participated as a speaker in an educational session for La Roche-Posay.

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20 **Pr. Wei** reports personal fees from La Roche Posay during the conduct of the study. **A.-L. Demessant-Flavigny**, **C. Le Floc'h**, **Dr D. Kerob** are employees of La Roche Posay.

21

22 **Pr. Dreno** reports personal fees from La Roche Posay International during the conduct of the study. **Pr. Krutmann** reports personal fees from La Roche Posay during the conduct of the study and grants and personal fees from L'Oréal.

23

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25 **Data availability:** The data that support the findings of this study are available from the corresponding author upon reasonable request.

26

27 **Ethics statement:** This survey was conducted has been carried out according to the ICC/ESOMAR code of conduct.

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1 Dear Editor, Chronic UV-induced damages can result in benign conditions like skin aging
2 (photoaging) or more serious problems like skin cancers (non-melanoma skin cancers
3 and melanoma). Despite a large literature, multiple awareness campaigns, and a quite
4 good understanding regarding risks of acute and chronic sun exposure on skin damage,
5 individuals still have inappropriate behaviours towards sun exposure around the world.¹

6 While some people protect themselves by fear of photoaging, others are more
7 concerned about developing skin cancer. We conducted a study in 17 countries to
8 assess factors related to photoprotection by fear of skin cancer vs fear of photoaging
9 and evaluate protection practices in both groups.

10 The survey was conducted online from 28 September to 18 October 2021. The study
11 population, selected (using the quota method) from the Ipsos online Panel (3,540,000
12 panellists in 17 countries), included men and women aged 18 years and older from: the
13 United States of America (US), Brazil, Mexico, Argentina, Canada, Germany, France,
14 Spain, Italy, United Kingdom, Russia, South Africa, Egypt, China, Japan, Indonesia and
15 Australia. A total of 17,001 individuals were surveyed. We asked patients to state whether
16 they fear or not skin cancer or/and photoaging and what their sun protection habits are.

17 Questionnaires were translated into the appropriate languages for each country and
18 proofread by a native speaker.

19 There were 9007 females, of which 586 feared only skin cancer (6.5%) vs 2086 (23.2%)
20 who feared only photoaging and 3686 (40.9%) who feared both. The proportion of those
21 who feared only skin cancer was 15.7% in Australia, 7% in West Europe, and 4.3% in East
22 Europe. The proportion of those who feared only photoaging was 26.3% in Asia, 26.2% in
23 East Europe, and 19.7% in West Europe. (Table 1)
1 Dear Editor, Chronic UV-induced damages can result in benign conditions like skin aging
2 (photoaging) or more serious problems like skin cancers (non-melanoma skin cancers
3 and melanoma). Despite a large literature, multiple awareness campaigns, and a quite
4 good understanding regarding risks of acute and chronic sun exposure on skin damage,
5 individuals still have inappropriate behaviours towards sun exposure around the world.¹

6 While some people protect themselves by fear of photoaging, others are more
7 concerned about developing skin cancer. We conducted a study in 17 countries to
8 assess factors related to photoprotection by fear of skin cancer vs fear of photoaging
9 and evaluate protection practices in both groups.

10 The survey was conducted online from 28 September to 18 October 2021. The study
11 population, selected (using the quota method) from the Ipsos online Panel (3,540,000
12 panellists in 17 countries), included men and women aged 18 years and older from: the
13 United States of America (US), Brazil, Mexico, Argentina, Canada, Germany, France,
14 Spain, Italy, United Kingdom, Russia, South Africa, Egypt, China, Japan, Indonesia and
15 Australia. A total of 17,001 individuals were surveyed. We asked patients to state whether
16 they fear or not skin cancer or/and photoaging and what their sun protection habits are.

17 Questionnaires were translated into the appropriate languages for each country and
18 proofread by a native speaker.

19 There were 9007 females, of which 586 feared only skin cancer (6.5%) vs 2086 (23.2%)
20 who feared only photoaging and 3686 (40.9%) who feared both. The proportion of those
21 who feared only skin cancer was 15.7% in Australia, 7% in West Europe, and 4.3% in East
22 Europe. The proportion of those who feared only photoaging was 26.3% in Asia, 26.2% in
23 East Europe, and 19.7% in West Europe. (Table 1)
1 The results show that concern about skin cancer was highest in Australia followed by
2 North America, and lowest in Eastern Europe (Table 1). In fact, Australia has one of the
3 highest rates of skin cancer in the world, with around 440,000 newly diagnosed cases
4 every year, due to the country's hot, dry climate, outdoor sporting culture, and globally
5 high levels of UV radiation. ²,³ In an attempt to change the nation's pro-tanning attitudes,
6 public health campaigns were launched to increase the population's skin cancer
7 awareness. On the contrary, concerns about photoaging were lowest in Australia and
8 highest in Asia and West Europe. Males were significantly more fearful of skin cancer, and
9 females were more fearful of photoaging. In fact, fear and anxiety about aging have been
10 increasing amongst females in the past years.⁴ Surprisingly, age, prototype and standard
11 of living had no impact on concerns about skin cancer or photoaging. Taking into account
12 that subjects with light prototypes are at higher risk of developing skin cancers, there
13 seems to be an unmet need regarding the proper education of this population, as <10%
14 were concerned about skin cancer in this survey. Interestingly, compared to subjects
15 fearful of skin cancer, those fearful of photoaging were more likely to apply sunscreen on
16 a daily basis, and in sunny days, to wear a hat, sunglasses, clothes for protection, seek
17 shade, and avoid sun time in midday (Table 2).

18 Nevertheless, there is scarce evidence on differences in sun exposure habits between
19 individuals with high risk and low risk of skin cancer.⁶⁻⁸

20 Studies have shown that raising awareness of the risk factors of skin cancer had no impact
21 on sun exposure behavior (family history of melanoma, presence of large/atypical nevi
22 and childhood sunburn)⁶. Our results demonstrated a significant concern about
23 photoaging compared to skin cancer. Therefore, shedding lights on photoaging could be
1 The results show that concern about skin cancer was highest in Australia followed by
2 North America, and lowest in Eastern Europe (Table 1). In fact, Australia has one of the
3 highest rates of skin cancer in the world, with around 440,000 newly diagnosed cases
4 every year, due to the country's hot, dry climate, outdoor sporting culture, and globally
5 high levels of UV radiation. ²,³ In an attempt to change the nation's pro-tanning attitudes,
6 public health campaigns were launched to increase the population's skin cancer
7 awareness. On the contrary, concerns about photoaging were lowest in Australia and
8 highest in Asia and West Europe. Males were significantly more fearful of skin cancer, and
9 females were more fearful of photoaging. In fact, fear and anxiety about aging have been
10 increasing amongst females in the past years.⁴ Surprisingly, age, prototype and standard
11 of living had no impact on concerns about skin cancer or photoaging. Taking into account
12 that subjects with light prototypes are at higher risk of developing skin cancers, there
13 seems to be an unmet need regarding the proper education of this population, as <10%
14 were concerned about skin cancer in this survey. Interestingly, compared to subjects
15 fearful of skin cancer, those fearful of photoaging were more likely to apply sunscreen on
16 a daily basis, and in sunny days, to wear a hat, sunglasses, clothes for protection, seek
17 shade, and avoid sun time in midday (Table 2).

18 Nevertheless, there is scarce evidence on differences in sun exposure habits between
19 individuals with high risk and low risk of skin cancer.⁶⁻⁸

20 Studies have shown that raising awareness of the risk factors of skin cancer had no impact
21 on sun exposure behavior (family history of melanoma, presence of large/atypical nevi
22 and childhood sunburn)⁶. Our results demonstrated a significant concern about
23 photoaging compared to skin cancer. Therefore, shedding lights on photoaging could be
1 an important part of future skin cancer awareness campaigns. Addressing people's fear

2 about photoaging on top of own concern about skin cancer should be assessed, as it

3 might constitute a paradigm shift in sun exposure habits of people.

4

5 References

1. Auerbach MV, Heckman CJ, Darlow S. To protect or not to protect: examining

7 reasons for sun protection among young women at risk for skin cancer. J Behav

8 Med. 2018 Aug;41(4):528-536. doi: 10.1007/s10865-018-9920-0. Epub 2018 Mar

9 27. PMID: 29589257; PMCID: PMC6031451.

10 2. Deva M, Osborne J, McGlynn A, Soars L, Loghdey S, Beath K, Gonski P, Dwyer P,

11 Vasudeva N, Joshi P, Deva A. Disease Focused Integrated Care - a New Model of

12 Healthcare Delivery for the Treatment of Skin Cancer. Int J Integr Care. 2023 May

13 5;23(2):12. doi: 10.5334/ijic.7009. PMID: 37151779; PMCID: PMC10162353.

14 3. Lo Presti L, Chang P, Taylor MF. Young Australian adults' reactions to viewing

15 personalised UV photoaged photographs. Australas Med J. 2014 Nov

16 30;7(11):454-61. doi: 10.4066/AMJ.2014.2253. PMID: 25550717; PMCID:

17 PMC4259210.

18 4. Mahoney B. Aging Anxieties and Disturbed Eating in Female Students: It's not all

19 About Aging Appearance Concern. Eur J Psychol. 2018 Mar 12;14(1):7-27. doi:

20 10.5964/ejop.v14i1.1390. PMID: 29899795; PMCID: PMC5973514.

21 5. Passeron T, Lim HW, Goh CL, Kang HY, Ly F, Morita A, Ocampo Candiani J, Puig

22 S, Schalka S, Wei L, Dréno B, Krutmann J. Photoprotection according to skin
1 an important part of future skin cancer awareness campaigns. Addressing people's fear

2 about photoaging on top of own concern about skin cancer should be assessed, as it

3 might constitute a paradigm shift in sun exposure habits of people.

4

5 References

1. Auerbach MV, Heckman CJ, Darlow S. To protect or not to protect: examining

7 reasons for sun protection among young women at risk for skin cancer. J Behav

8 Med. 2018 Aug;41(4):528-536. doi: 10.1007/s10865-018-9920-0. Epub 2018 Mar

9 27. PMID: 29589257; PMCID: PMC6031451.

10 2. Deva M, Osborne J, McGlynn A, Soars L, Loghdey S, Beath K, Gonski P, Dwyer P,

11 Vasudeva N, Joshi P, Deva A. Disease Focused Integrated Care - a New Model of

12 Healthcare Delivery for the Treatment of Skin Cancer. Int J Integr Care. 2023 May

13 5;23(2):12. doi: 10.5334/ijic.7009. PMID: 37151779; PMCID: PMC10162353.

14 3. Lo Presti L, Chang P, Taylor MF. Young Australian adults' reactions to viewing

15 personalised UV photoaged photographs. Australas Med J. 2014 Nov

16 30;7(11):454-61. doi: 10.4066/AMJ.2014.2253. PMID: 25550717; PMCID:

17 PMC4259210.

18 4. Mahoney B. Aging Anxieties and Disturbed Eating in Female Students: It's not all

19 About Aging Appearance Concern. Eur J Psychol. 2018 Mar 12;14(1):7-27. doi:

20 10.5964/ejop.v14i1.1390. PMID: 29899795; PMCID: PMC5973514.

21 5. Passeron T, Lim HW, Goh CL, Kang HY, Ly F, Morita A, Ocampo Candiani J, Puig

22 S, Schalka S, Wei L, Dréno B, Krutmann J. Photoprotection according to skin
1 phototype and dermatoses: practical recommendations from an expert panel. J Eur Acad Dermatol Venereol. 2021 Jul;35(7):1460-1469. doi: 10.1111/jdv.17242. Epub 2021 May 4. PMID: 33764577; PMCID: PMC8252523.

6. Karlsson O, Hagberg O, Nielsen K, Paoli J, Ingvar Å. Difference in Sun Exposure Habits Between Individuals with High and Low Risk of Skin Cancer. Dermatol Pract Concept. 2021 Sep 1;11(4):e2021090. doi: 10.5826/dpc.1104a90. PMID: 34631260; PMCID: PMC8480439.

7. Passeron T, Lim HW, Goh CL, Kang HY, Ly F, Morita A, Ocampo-Candiani J, Puig S, Schalka S, Liu W, Demessant-Flavigny AL, Le Floc'h C, Kerob D, Dreno B, Krutmann J. Sun exposure behaviours as a compromise to paradoxical injunctions: Insight from a worldwide survey. J Eur Acad Dermatol Venereol. 2023 Aug 17. doi: 10.1111/jdv.19421. Epub ahead of print. PMID: 37590528.

8. Falk M, Faresjo A, Faresjo T, et al. Sun exposure habits and health risk-related behaviours among individuals with previous history of skin cancer. *Anticancer research*. 2013;33(2):631-8.

9. Stratigos AJ, Forsea AM, van der Leest RJ, de Vries E, Nagore E, Bulliard JL, et al. Euromelanoma: a dermatology-led European campaign against nonmelanoma skin cancer and cutaneous melanoma. Past, present and future. *The British journal of dermatology*. 2012;167(Suppl 2):99-104.

10. Hajdarevic S, Hvidberg L, Lin Y, Donnelly C, Gavin A, Lagerlund M, et al. Awareness of sunburn in childhood, use of sunbeds and change of moles in Denmark, Northern Ireland, Norway and Sweden. *European journal of public health*. 2016;26(1):29-35. doi: 10.1093/eurpub/ckv112.
1 phototype and dermatoses: practical recommendations from an expert panel. J Eur Acad Dermatol Venereol. 2021 Jul;35(7):1460-1469. doi: 10.1111/jdv.17242. Epub 2021 May 4. PMID: 33764577; PMCID: PMC8252523.

6. Karlsson O, Hagberg O, Nielsen K, Paoli J, Ingvar Å. Difference in Sun Exposure Habits Between Individuals with High and Low Risk of Skin Cancer. Dermatol Pract Concept. 2021 Sep 1;11(4):e2021090. doi: 10.5826/dpc.1104a90. PMID: 34631260; PMCID: PMC8480439.

7. Passeron T, Lim HW, Goh CL, Kang HY, Ly F, Morita A, Ocampo-Candiani J, Puig S, Schalka S, Liu W, Demessant-Flavigny AL, Le Floc'h C, Kerob D, Dreno B, Krutmann J. Sun exposure behaviours as a compromise to paradoxical injunctions: Insight from a worldwide survey. J Eur Acad Dermatol Venereol. 2023 Aug 17. doi: 10.1111/jdv.19421. Epub ahead of print. PMID: 37590528.

8. Falk M, Faresjo A, Faresjo T, et al. Sun exposure habits and health risk-related behaviours among individuals with previous history of skin cancer. *Anticancer research*. 2013;33(2):631-8.

9. Stratigos AJ, Forsea AM, van der Leest RJ, de Vries E, Nagore E, Bulliard JL, et al. Euromelanoma: a dermatology-led European campaign against nonmelanoma skin cancer and cutaneous melanoma. Past, present and future. *The British journal of dermatology*. 2012;167(Suppl 2):99-104.

10. Hajdarevic S, Hvidberg L, Lin Y, Donnelly C, Gavin A, Lagerlund M, et al. Awareness of sunburn in childhood, use of sunbeds and change of moles in Denmark, Northern Ireland, Norway and Sweden. *European journal of public health*. 2016;26(1):29-35. doi: 10.1093/eurpub/ckv112.
<table><caption>1 Table 1: Individuals fearing skin cancer (SC) vs photoaging (PA) vs both</caption><thead><tr><th rowspan="2"></th><th rowspan="2"></th><th rowspan="2">N</th><th colspan="2">SC</th><th colspan="2">PA</th><th colspan="2">SC+PA</th><th rowspan="2">P value SC vs PA</th></tr><tr><th>N</th><th>%</th><th>N</th><th>%</th><th>N</th><th>%</th></tr></thead><tbody><tr><td></td><td></td><td>Total</td><td>1295</td><td>10,0</td><td>3413</td><td>17,2</td><td>6290</td><td>36,4</td><td>&lt;10<sup>-3</sup></td></tr><tr><td rowspan="7">REGION (based on weight of each country)</td><td>Asia</td><td>3001</td><td>143</td><td>4,8</td><td>802</td><td>26,3</td><td>1371</td><td>44,4</td><td rowspan="7">&lt;10<sup>-3</sup></td></tr><tr><td>West Europe</td><td>5000</td><td>360</td><td>7,0</td><td>930</td><td>19,7</td><td>1740</td><td>35,5</td></tr><tr><td>North America</td><td>2000</td><td>275</td><td>12,9</td><td>247</td><td>13,2</td><td>658</td><td>35,6</td></tr><tr><td>Australia</td><td>1000</td><td>157</td><td>15,7</td><td>100</td><td>10,0</td><td>462</td><td>46,2</td></tr><tr><td>South America</td><td>3000</td><td>160</td><td>4,7</td><td>715</td><td>25,1</td><td>1209</td><td>39,7</td></tr><tr><td>Africa</td><td>2000</td><td>157</td><td>5,4</td><td>357</td><td>18,6</td><td>627</td><td>26,5</td></tr><tr><td>East Europe</td><td>1000</td><td>43</td><td>4,3</td><td>262</td><td>26,2</td><td>223</td><td>22,3</td></tr><tr><td rowspan="2">Sex</td><td>Male</td><td>7994</td><td>709</td><td>8,9</td><td>1327</td><td>16,6</td><td>2607</td><td>32,6</td><td rowspan="2">&lt;10<sup>-3</sup></td></tr><tr><td>Female</td><td>9007</td><td>586</td><td>6,5</td><td>2086</td><td>23,2</td><td>3683</td><td>40,9</td></tr><tr><td rowspan="4">AGE</td><td>[16,20]</td><td>421</td><td>36</td><td>8,6</td><td>82</td><td>19,5</td><td>122</td><td>29,0</td><td rowspan="4">0.2</td></tr><tr><td>[20,34]</td><td>5185</td><td>417</td><td>8,0</td><td>1059</td><td>20,4</td><td>1736</td><td>33,5</td></tr><tr><td>[35,54]</td><td>6296</td><td>438</td><td>7,0</td><td>1266</td><td>20,1</td><td>2506</td><td>39,8</td></tr><tr><td>&gt;54</td><td>5099</td><td>404</td><td>7,9</td><td>1006</td><td>19,7</td><td>1926</td><td>37,8</td></tr><tr><td rowspan="3">Education Levels</td><td>Low</td><td>2672</td><td>194</td><td>7,3</td><td>562</td><td>21,0</td><td>958</td><td>35,9</td><td rowspan="3">0.002</td></tr><tr><td>Medium</td><td>6157</td><td>510</td><td>8,3</td><td>1157</td><td>18,8</td><td>2161</td><td>35,1</td></tr><tr><td>High</td><td>8172</td><td>591</td><td>7,2</td><td>1694</td><td>20,7</td><td>3171</td><td>38,8</td></tr><tr><td rowspan="3">Standard of living</td><td>Low</td><td>4597</td><td>355</td><td>7,7</td><td>861</td><td>18,7</td><td>1546</td><td>33,6</td><td rowspan="3">0.2</td></tr><tr><td>Medium</td><td>5612</td><td>416</td><td>7,4</td><td>1173</td><td>20,9</td><td>2120</td><td>37,8</td></tr><tr><td>High</td><td>5433</td><td>418</td><td>7,7</td><td>1120</td><td>20,6</td><td>2172</td><td>40,0</td></tr><tr><td rowspan="2">Phototype</td><td>I,II,III</td><td>12875</td><td>985</td><td>7,7</td><td>2568</td><td>19,9</td><td>4923</td><td>38,2</td><td rowspan="2">0.58</td></tr><tr><td>IV,V,VI</td><td>4126</td><td>310</td><td>7,5</td><td>845</td><td>20,5</td><td>1367</td><td>33,1</td></tr></tbody></table>
<table><caption>1 Table 1: Individuals fearing skin cancer (SC) vs photoaging (PA) vs both</caption><thead><tr><th rowspan="2"></th><th rowspan="2"></th><th rowspan="2">N</th><th colspan="2">SC</th><th colspan="2">PA</th><th colspan="2">SC+PA</th><th rowspan="2">P value SC vs PA</th></tr><tr><th>N</th><th>%</th><th>N</th><th>%</th><th>N</th><th>%</th></tr></thead><tbody><tr><td></td><td></td><td>Total</td><td>1295</td><td>10,0</td><td>3413</td><td>17,2</td><td>6290</td><td>36,4</td><td>&lt;10<sup>-3</sup></td></tr><tr><td rowspan="7">REGION (based on weight of each country)</td><td>Asia</td><td>3001</td><td>143</td><td>4,8</td><td>802</td><td>26,3</td><td>1371</td><td>44,4</td><td rowspan="7">&lt;10<sup>-3</sup></td></tr><tr><td>West Europe</td><td>5000</td><td>360</td><td>7,0</td><td>930</td><td>19,7</td><td>1740</td><td>35,5</td></tr><tr><td>North America</td><td>2000</td><td>275</td><td>12,9</td><td>247</td><td>13,2</td><td>658</td><td>35,6</td></tr><tr><td>Australia</td><td>1000</td><td>157</td><td>15,7</td><td>100</td><td>10,0</td><td>462</td><td>46,2</td></tr><tr><td>South America</td><td>3000</td><td>160</td><td>4,7</td><td>715</td><td>25,1</td><td>1209</td><td>39,7</td></tr><tr><td>Africa</td><td>2000</td><td>157</td><td>5,4</td><td>357</td><td>18,6</td><td>627</td><td>26,5</td></tr><tr><td>East Europe</td><td>1000</td><td>43</td><td>4,3</td><td>262</td><td>26,2</td><td>223</td><td>22,3</td></tr><tr><td rowspan="2">Sex</td><td>Male</td><td>7994</td><td>709</td><td>8,9</td><td>1327</td><td>16,6</td><td>2607</td><td>32,6</td><td rowspan="2">&lt;10<sup>-3</sup></td></tr><tr><td>Female</td><td>9007</td><td>586</td><td>6,5</td><td>2086</td><td>23,2</td><td>3683</td><td>40,9</td></tr><tr><td rowspan="4">AGE</td><td>[16,20]</td><td>421</td><td>36</td><td>8,6</td><td>82</td><td>19,5</td><td>122</td><td>29,0</td><td rowspan="4">0.2</td></tr><tr><td>[20,34]</td><td>5185</td><td>417</td><td>8,0</td><td>1059</td><td>20,4</td><td>1736</td><td>33,5</td></tr><tr><td>[35,54]</td><td>6296</td><td>438</td><td>7,0</td><td>1266</td><td>20,1</td><td>2506</td><td>39,8</td></tr><tr><td>&gt;54</td><td>5099</td><td>404</td><td>7,9</td><td>1006</td><td>19,7</td><td>1926</td><td>37,8</td></tr><tr><td rowspan="3">Education Levels</td><td>Low</td><td>2672</td><td>194</td><td>7,3</td><td>562</td><td>21,0</td><td>958</td><td>35,9</td><td rowspan="3">0.002</td></tr><tr><td>Medium</td><td>6157</td><td>510</td><td>8,3</td><td>1157</td><td>18,8</td><td>2161</td><td>35,1</td></tr><tr><td>High</td><td>8172</td><td>591</td><td>7,2</td><td>1694</td><td>20,7</td><td>3171</td><td>38,8</td></tr><tr><td rowspan="3">Standard of living</td><td>Low</td><td>4597</td><td>355</td><td>7,7</td><td>861</td><td>18,7</td><td>1546</td><td>33,6</td><td rowspan="3">0.2</td></tr><tr><td>Medium</td><td>5612</td><td>416</td><td>7,4</td><td>1173</td><td>20,9</td><td>2120</td><td>37,8</td></tr><tr><td>High</td><td>5433</td><td>418</td><td>7,7</td><td>1120</td><td>20,6</td><td>2172</td><td>40,0</td></tr><tr><td rowspan="2">Phototype</td><td>I,II,III</td><td>12875</td><td>985</td><td>7,7</td><td>2568</td><td>19,9</td><td>4923</td><td>38,2</td><td rowspan="2">0.58</td></tr><tr><td>IV,V,VI</td><td>4126</td><td>310</td><td>7,5</td><td>845</td><td>20,5</td><td>1367</td><td>33,1</td></tr></tbody></table>

2

3
<table><caption>Table 2: Protection habits in individuals fearing skin cancer (SC) vs photoaging (PA) vs both</caption><thead><tr><th></th><th>SC</th><th colspan="2">PA</th><th colspan="2">SC+PA</th><th>p value SC vs PA</th></tr></thead><tbody><tr><td>N (%)</td><td>11737</td><td colspan="2">11737</td><td colspan="2">11737</td><td></td></tr><tr><td>Sunscreen application every day</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>905</td><td>7,7</td><td>2480</td><td>21,1</td><td>4883</td><td>0.06</td></tr><tr><td>Wear hat on sunny days</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>763</td><td>8,1</td><td>1783</td><td>19,0</td><td>3840</td><td>&lt;10<sup>-3</sup></td></tr><tr><td>Use clothes for sun protection</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>585</td><td>7,7</td><td>1553</td><td>20,5</td><td>3163</td><td>0.8</td></tr><tr><td>Wear sunglasses on sunny days</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>764</td><td>8,0</td><td>1880</td><td>19,7</td><td>3831</td><td>0.01</td></tr><tr><td>Seek Shadow when it's sunny</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>982</td><td>7,4</td><td>2701</td><td>20,5</td><td>5131</td><td>0.01</td></tr><tr><td>Avoid sun time in the midday sun</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>793</td><td>7,1</td><td>2365</td><td>21,1</td><td>4464</td><td>&lt;10<sup>-3</sup></td></tr></tbody></table>
<table><caption>Table 2: Protection habits in individuals fearing skin cancer (SC) vs photoaging (PA) vs both</caption><thead><tr><th></th><th>SC</th><th colspan="2">PA</th><th colspan="2">SC+PA</th><th>p value SC vs PA</th></tr></thead><tbody><tr><td>N (%)</td><td>11737</td><td colspan="2">11737</td><td colspan="2">11737</td><td></td></tr><tr><td>Sunscreen application every day</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>905</td><td>7,7</td><td>2480</td><td>21,1</td><td>4883</td><td>0.06</td></tr><tr><td>Wear hat on sunny days</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>763</td><td>8,1</td><td>1783</td><td>19,0</td><td>3840</td><td>&lt;10<sup>-3</sup></td></tr><tr><td>Use clothes for sun protection</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>585</td><td>7,7</td><td>1553</td><td>20,5</td><td>3163</td><td>0.8</td></tr><tr><td>Wear sunglasses on sunny days</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>764</td><td>8,0</td><td>1880</td><td>19,7</td><td>3831</td><td>0.01</td></tr><tr><td>Seek Shadow when it's sunny</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>982</td><td>7,4</td><td>2701</td><td>20,5</td><td>5131</td><td>0.01</td></tr><tr><td>Avoid sun time in the midday sun</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>793</td><td>7,1</td><td>2365</td><td>21,1</td><td>4464</td><td>&lt;10<sup>-3</sup></td></tr></tbody></table>