International Journal of Audiology

ISSN: 1499-2027 (Print) 1708-8186 (Online) Journal homepage: http://www.tandfonline.com/loi/iija20

Usage of personal music players in adolescents

and its association with noise-induced hearing
loss: A cross-sectional analysis of Ohrkan cohort
study data

Dorothee Twardella, Ulla Raab, Carmelo Perez-Alvarez, Thomas Steffens,

Gabriele Bolte & Hermann Fromme

To cite this article: Dorothee Twardella, Ulla Raab, Carmelo Perez-Alvarez, Thomas Steffens,
Gabriele Bolte & Hermann Fromme (2016): Usage of personal music players in adolescents
and its association with noise-induced hearing loss: A cross-sectional analysis of Ohrkan
cohort study data, International Journal of Audiology, DOI: 10.1080/14992027.2016.1211762

To link to this article: http://dx.doi.org/10.1080/14992027.2016.1211762

Published online: 09 Aug 2016.

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 International Journal of Audiology 2016; Early Online: 1–8

Original Article

Usage of personal music players in adolescents and its

association with noise-induced hearing loss: A cross-sectional
analysis of Ohrkan cohort study data

Dorothee Twardella1,2, Ulla Raab1,3, Carmelo Perez-Alvarez4, Thomas Steffens4, Gabriele Bolte1,5
& Hermann Fromme6
1
Department of Occupational and Environmental Medicine and Epidemiology, Bavarian Health and Food Safety Authority, Munich, Germany,
2
Bavarian Health and Food Safety Authority, Centre for Early Cancer Detection and Cancer Registration, Nuremberg, Germany, 3Bavarian
Health and Food Safety Authority, Centre of Prevention and Health Promotion, Munich, Germany, 4Department of Otorhinolaryngology,
University Hospital Regensburg, Regensburg, Germany, 5Department of Social Epidemiology, University of Bremen, Institute of Public Health
and Nursing Research, Bremen, Germany, and 6Department of Toxicology and Chemical Safety, Bavarian Health and Food Safety Authority,
Munich, Germany

Abstract
Objective: To describe personal music player (PMP) usage among adolescents, sociodemographic determinants and association with
audiometric notches. Design: Audiometric evaluation to assess hearing status, and standardized questionnaires to evaluate PMP listening
behaviors, leisure noise exposures and self-reported hearing loss symptoms. Sociodemographic information was collected using a parent
questionnaire. Noise exposure by PMP usage equivalent for a 40 h week was estimated based on self-reported volume and duration of use.
Study sample: A total of 2143 students (54% females) attending 9th grade in Regensburg, Germany, during 2009 to 2011. Results: Overall,
85% of the students reported using PMPs. Exposure level exceeded 80 dB(A) in approximately one third, and 85 dB(A) in one quarter, of
those who used PMP. An audiometric notch was found in 2.3% of participants, but was not significantly associated with higher PMP
exposure. Conclusions: PMP exposure above the occupational limits of 80 and 85 dB(A) set by the Directive 2003/10/EC may be a risk
factor for developing noise-induced hearing loss. Educational measures to ameliorate high risk behaviors in PMP usage are needed,
particularly for socially disadvantaged groups.

Key Words: Noise; behavioral measures; demographics/epidemiology; pediatric

In the last decade personal music players (PMP) usage attained
great popularity among adolescents and young adults. MP3 players
and mobile phones are widely used to listen to music or podcasts
allowing long-time listening, while also having an increased
average output capability (Serra et al, 2012). Due to the lasting
popularity of these devices the potential harmful effects on hearing
is of public concern. These risks have been emphasized by the
Scientific Committee on Emerging and Newly Identified Health
Risks (SCENIHR) as well as by the World Health Organization
with their ‘Make listening safe’ initiative (SCENIHR, 2008).
In 2008, the SCENIHR declared that data on the usage of PMP
among adolescents is lacking and that empirical evidence on the
association between PMP usage and hearing loss is equivocal
(SCENIHR, 2008). Since the SCENIHR report was published, new
studies evaluating hearing status of adolescents by comparing
audiometric results between PMP exposure levels have emerged
(Babisch, 2009; Kim et al, 2009; Martinez-Wbaldo Mdel et al,
2009; Berg & Serpanos, 2011; Sekhar et al, 2011; Weichbold et al,
2012; Feder et al, 2013; Sulaiman et al, 2013). However, only in
some of these studies statistically significant associations between
PMP exposure and hearing could be found and the exposure
parameters found significantly associated with hearing loss differ
(see Supplementary Table E1 for data collection methods – online
only). Most studies were of small or medium size (between 177 and
600 participants) and thus likely lacked statistical power (Babisch,
2009; Kim et al, 2009; Martinez-Wbaldo Mdel et al, 2009; Sekhar
et al, 2011; Feder et al, 2013; Sulaiman et al, 2013). Only one study
showed a statistically significant association between a high PMP

Correspondence: Dorothee Twardella, Schweinauer Hauptstr. 80, 90441 Nuremberg, Germany. Tel: +49 9131 2921. Fax: +49 9131 2905 4297. E-mail:
Dorothee.Twardella@lgl.bayern.de

(Received 28 October 2015; revised 20 June 2016; accepted 7 July 2016)

ISSN 1499-2027 print/ISSN 1708-8186 online ß 2016 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
DOI: 10.1080/14992027.2016.1211762
2 D. Twardella et al.
Abbreviations
4kHzHL hearing loss at 4 kHz (HL 415 dB)
AV80 lower exposure action value of 80 dB(A)
AV85 upper exposure action value of 85 dB(A)
CI Confidence Interval
daPa dekapascal
dB(A) A-weighted decibel
HFHL high frequency hearing loss
kHz kilohertz
LFHL low frequency hearing loss
OR Odds Ratio
PMP Personal Music Players
SCENIHR Scientific Committee on Emerging and Newly
Identified Health Risks
SPL Sound Pressure Level
exposure and hearing loss (Feder et al, 2013), while the others
produced negative or mixed results. In the study by Feder et al.
(2013), careful consideration was given to accurately determining
the PMP exposure level and hearing loss for each subject: PMP
output levels were measured and combined with self-reported
duration of usage to compute an energy equivalent sound pressure
level (SPL) produced from PMP usage. Hearing loss was identified
by pure tone audiometry considering also tympanometry and
otoscopy. The Feder et al. (2013) study reported an association
between ‘typical’ measured sound pressure levels (reported by
participants as their ‘typical’ listening volume) and audiometric
thresholds at 4 kHz and low frequency pure tone average (0.5, 1,
2 kHz) which led the authors to conclude that typical listening PMP
volumes/durations may be contributing to NIHL at some
frequencies.
The two large studies both produced significant results, although
the assessment of PMP usage and hearing loss was less precise
(Berg & Serpanos, 2011; Weichbold et al., 2012). In the study by
Weichbold et al. (2012) involving 1296 Grade 9 students, partici-
pants were asked to choose from among six usage duration
categories while audiometric screening was conducted (2, 4, 6 kHz;
20 dB hearing loss threshold). The risk to fail screening at at least
one frequency was increased in those students which selected the
two highest categories of duration of use. The study by Berg and
Serpanos (2011) comprised a selected population of 8710 female
adolescents belonging to a residential foster care facility dedicated
to vulnerable groups. While a significant association was found
between PMP usage and high frequency hearing loss, there was no
significant association observed between duration of usage and
hearing loss. SPL measures were not carried out.
Large epidemiologic studies which take both the duration of use
and the volume level into account for the estimation of PMP
exposure and in addition include audiometric evaluation of hearing
are rare. The study by Vogel et al, among about 1500 adolescents
aged 12–19 years provides much data on patterns and determinants
of PMP usage but does not include audiometric examinations
(Vogel et al, 2011). In contrast, audiometric data of 4310
adolescents aged 12–19 years were collected in an US study, but
information on leisure noise exposure was only reported in a
subsample of 1791 participants (Henderson et al, 2011). Also,
leisure noise exposure was defined by one dichotomous item only
(as ever been exposed to steady loud noise or music for 5 h/week
outside of job). Thus large studies are needed with thorough
exposure assessment as well as audiometric examination following
clinical standards to gain insight into the public health relevance of
the potential problem. Towards this end, this prospective cohort
study Ohrkan was initiated in Germany. The current paper presents
survey results and a description of the PMP usage in adolescents as
well as sociodemographic determinants and associations with
hearing loss.
Methods
The methods and study design of the Ohrkan study have been
published elsewhere and will be described here briefly (Twardella et
al, 2011; Twardella et al, 2013). Informed consent was obtained
from students and their parents. The Ethics Committee of the
University Hospital of Regensburg approved the study including its
data protection procedures.
Participants
All students who attended the 9th grade of any school in the city of
Regensburg, Germany, in the academic year 2009/2010 or 2010/
2011 were eligible for participation.
Recruitment
Among the 27 schools in Regensburg, all except one remedial
school with 11 eligible subjects (four girls, seven boys) were
involved in recruitment efforts. This resulted in 3846 eligible
students. No exclusion criteria were applied.
Participation rate
Overall, 2149 (55.9%) students participated in Ohrkan. One student
withdrew consent subsequently and five had to be excluded from
the current analysis because they did not return the questionnaire
leaving a final sample size of 2143.
Procedure
A study information package, consent forms and questionnaires
were distributed to students. Those interested in participating
completed the questionnaire at home. The standardized question-
naire for students included 106 items related to music listening
behavior, noise exposures, self-reported hearing loss symptoms, and
well-being. Parents were asked to complete a 63-item questionnaire
consisting of sociodemographic and medical history questions.
Participants were invited to contact the study team should
clarification be needed. Approximately one week following the
distribution of study packages, a team member visited each
classroom to discuss the study and answer questions.
Adolescents were asked to take part in audiometric evaluation.
Appointments were made after the visit of the study team member
in class. Questionnaires could be either returned at this visit, by mail
or at the upcoming audiometric evaluation.
Estimation of noise exposure due to PMP usage
The use of personal music players was assessed on the basis of three
items reported by the participants in the questionnaire: use of
personal music players within the last week (‘Did you listen to
music during the last week using either a MP3-player, a mobile

phone or any other portable player with headphones/earphones?’ –
(1) ‘No, not at all,’ (2) ‘Yes, I have listened to music during the last
week using a portable player.’), duration of use (‘For how many
hours in total did you listen to music during the last week using a
MP3-player or any other portable player?’ – ‘XXX hours in total’)
and usual level of volume control (‘How do you usually set the
volume control on your player? Compare your volume control
setting to the maximal setting. For example, on my player settings
between 1 and 30 are possible. If I set my volume on ‘15,’ this is
hence 50% of the maximal volume setting. Again please consider
the last week.’ – ‘about XXX % of the maximal volume control
setting’) .
Participants who reported to have used a PMP during the last
week were classified as ‘users,’ all others as ‘non-users.’ Noise
exposure due to PMP usage was quantified by averaging the output
SPLs from several PMPs using six volume categories, as described
by Portnuff et al (2011). The volume categories used in this study
are as follows: (1) 55% of the maximum – noise exposure was
considered negligible, (2) 55–64% equates to 77 dB(A), (3) 65–74%
equates to 83.2 dB(A), (4) 75–84% equates to 89.4 dB(A), (5) 85–
94% equates to 95.6 dB(A), and (6) 95–100% equates to
101.8 dB(A).
The thus derived usual SPL which applies to the reported
duration of use per week was converted to the noise exposure level as
if duration would have been 40 h per week: LEX, 40h ¼ LAeq,Te + 10 lg
* (Te/T0) where LAeq,Te represents the estimated usual SPL, Te the
reported exposure time in hours per week and T0 the reference
duration of 40 h (ISO 1999, 2013). These noise exposure levels
were compared to the ‘noise at work’ limits which pertain to a
40 h working week: the lower exposure action value of 80 dB(A)
(AV80) and the upper exposure action value of 85 dB(A) (AV85)
of Directive 2003/10/EC of the European Parliament and of the
Council (2003).
Audiometric measures
Audiometric testing was conducted at the Department of
Otorhinolaryngology at the University Hospital Regensburg by
experienced clinic staff using standardized procedures described
previously elsewhere (Twardella et al, 2013). In brief, compliance
testing and audiometry were conducted in two sound-attenuated
rooms with comparable equipment. For compliance testing
MADSEN Zodiac 901 Tympanometer was used in both rooms.
Failure of tympanogram was defined as (a) a peak of the curve at
pressure below 100 daPa (low pressure), or (b) a peak of the curve
at pressure above +100 daPa (excess pressure), or (c) no peak
observable. In case of failure, a physician inspected the ear,
removed occluding material such as earwax, and tympanometry was
repeated. Audiometry was performed with Madsen/GN Resound
Audiometer Aurical and headphone Holmco PD95 in the one and
MADSEN Itera II Diagnostik-Audiometer with headphone
Sennheiser HDA200 in the other room. Both audiometers comply
with DIN EN 60645-1:2002-9. Air conduction thresholds were
determined in each ear for the frequencies 1000 Hz, 2000 Hz,
3000 Hz, 4000 Hz, 6000 Hz, 8000 Hz, 500 Hz, 250 Hz, 125 Hz
across intensity ranges of 10 to 110 dB using 5-dB step intervals.
In the analysis of audiometric data only subjects who passed
tympanometry in both ears were considered. An audiometric notch
in at least one ear was considered an indicator of noise-induced
hearing loss. In accordance with criteria developed by Niskar et al,
an audiometric notch was considered present if (1) threshold values
Personal music player usage among adolescents 3
at 0.5 and 1 kHz were 15 dB (better), and (2) the maximum
(poorer) threshold value at 3, 4, or 6 kHz was at least 15 dB higher
(poorer) than the highest (poorest) threshold value for 0.5 and
1 kHz, and (3) the threshold value at 8 kHz was at least 10 dB lower
(better) than the maximum (poorest) threshold value for 3, 4, or
6 kHz (Niskar et al, 2001). As secondary outcomes, in accordance
with Henderson et al (2011), low frequency hearing loss (LFHL,
average of 0.5, 1, and 2 kHz HL 415 dB) and high frequency
hearing loss (HFHL, average of 3, 4, and 6 kHz HL 415 dB), and
additionally hearing loss at 4 kHz (4kHzHL, HL at 4 kHz 415 dB)
were considered.
Pilot study
The whole process of data collection including the recruitment, the
administration of questionnaires, and the organization and imple-
mentation of the audiometric evaluation was tested in a pilot study.
Two classes of grade nine in the school year preceding Ohrkan were
selected and 30 students participated. Returned questionnaires were
appraised with respect to completeness, internal consistency and
plausibility and this resulted in minor changes to wording.
Statistical methods and analysis
Only completed questionnaire responses were analyzed.
Sociodemographic characteristics of participants were analyzed
and tested for significance using Pearson’s Chi Square with respect
to differences in self-reported PMP usage and volume settings.
Migration background was categorized ‘none’ if the subject was
born in Germany, had German parents and German was the only
language spoken at home. Otherwise, if both the mother and father
were of German nationality, but the subject was born abroad and/or
if foreign languages were spoken at home, the category ‘possible’
was chosen. Migration background was categorized ‘yes’ in case of
foreign nationality of father and/or mother.
Significance of differences in use duration by sociodemographic
characteristics were tested by applying the Kruskal-Wallis test.
Determinants of PMP usage were identified among socio-
demographic variables during bivariate analysis (secondary school
types, school ownership, sex, age, native country, migration
background, parental education, marital status, single parenthood).
After evaluating multi-collinearity, the association between exceed-
ing AV80 and AV85 and school type, sex, age, native country and
marital status of parent was analyzed applying multivariate
regression.
Finally, bivariate logistic regression was applied to evaluate the
association between AV80 and AV85 and the indicators of hearing
loss. All statistical computations were performed with SAS
statistical software, version 9.2.
Results
Table 1 presents overall study population characteristics and
percentage of PMP usage by characteristic. The age range of 77%
of the participants was 15–16 years, 54% were female. Of 2143
participants, 85% reported PMP usage within the last week. Usage
of PMP was significantly more prevalent among participants from
non-university preparatory school types, among female participants,
and among those whose parents had a lower education level.
Listening duration was reported by 1780 PMP users and
ranged between 1 hour per week (5% percentile) and 35 hours per
4 D. Twardella et al.

Table 1. Characteristics of the study population in Ohrkan and percent usage of personal music player.
Total N (column %) Usage of PMP N (row %)
School Public 1464 (68.3) 1230 (84.9)
Private 679 (31.7) 588 (87.8)
Secondary school typesb Förderschule 59 (2.8) 57 (96.6)a
Hauptschule 571 (26.6) 501 (89.2)
Real-/Wirtschaftsschule 544 (25.4) 478 (88.8)
Gymnasium 969 (45.2) 782 (81.5)
Sex Female 1155 (53.9) 1014 (88.6)a
Male 988 (46.1) 804 (82.6)
Age (missing ¼ 21) 13–14 years 300 (14.1) 259 (86.9)
15 years 915 (43.1) 760 (83.8)
16 years 714 (33.7) 606 (86.2)
17–19 years 193 (9.1) 172 (90.5)
Place of birth (missing ¼ 29) Germany 1948 (92.2) 1650 (85.5)
Abroad 166 (7.9) 141 (87.6)
Migration background (missing ¼ 95) None 1548 (75.6) 1302 (84.9)
Possible 191 (9.3) 154 (82.4)
Certain 309 (15.1) 269 (88.8)
Parental education (missing ¼ 70) Low 341 (16.5) 306 (90.8)a
Medium 622 (30.0) 543 (88.0)
High 1110 (53.5) 907 (82.8)
Marital status (missing ¼ 45) Single 94 (4.5) 87 (93.6)
Married/reg. partnership 1609 (76.7) 1350 (84.7)
Divorced 349 (16.6) 295 (85.5)
Widowed 46 (2.2) 42 (95.5)
Single parenthood (missing ¼ 41) No 1696 (80.7) 1429 (85.2)
Yes 406 (19.3) 349 (87.0)

PMP: personal music player, N: number.

a
p for difference between groups50.05.
b
Förderschule: special school for students who have special educational needs. Hauptschule ¼ general, vocationally
oriented secondary school for non-university bound pupils, Realschule ¼ professionally oriented secondary school,
Wirtschaftsschule ¼ business school, Gymnasium ¼ university-preparatory secondary school, high school equivalent.

week (95% percentile) with a median of 6 hours per week
(mean 10.7 h/week). Volume control settings were available for
1696 users, of which 41% reported usually listening to music at less
than 55% of the maximum volume for their respective PMP. The
median volume control setting range was455 to565%, corres-
ponding to a SPL of 77 dB(A).
For 1670 PMP users, data on duration of use and volume
settings, from which noise exposure levels could be derived, were
available. A total of 32% of PMP users exceeded the AV80 and
22% the AV85. If the 301 non-users were considered in addition
and were put into the lowest exposure category, exposure was
distributed as follows:580 dB(A): 73%, 80 dB(A) to 85 dB(A)
9%,485 dB(A) to 90 dB(A): 6%,490 dB(A): 13%. Thus, of both
PMP-users and non-users combined, 27% and 19% exceeded the
AV80 and AV85, respectively.
Duration of use and volume level among PMP users was
significantly different between sociodemographic groups (see
Table 2). Generally, listening durations as well as volume levels
were higher in socially disadvantaged groups, i.e. in those attending
vocation training schools (p50.0001), possessing a migration
background (p50.0001), with less educated parents (p50.0001), or
with marital status of the parent being single (p ¼ 0.02 and p50,01,
respectively). No significant difference in the duration of PMP use
between male and female participants was observed, but volume
control setting was typically higher in males (p50.001). Duration
of use increased significantly with age (p50.0001) but such a trend
was not also observed with volume and age.
Correspondingly, in bivariate regression analysis all participants
including non-users who were at a social disadvantage were
significantly higher exposed (data not shown). Multivariate logistic
regression revealed that secondary school type and marital status
were independently associated with music listening behavior
(Table 3). Relative to those attending Gymnasium (high school
equivalent), risky listening increased among participants in the
Real-/Wirtschaftsschule (AV80: Odds Ratio (OR) ¼ 1.58, 95%
Confidence Interval (CI) 1.21–2.06; AV85: OR ¼ 1.82, 95% CI
1.32–2.51), in Hauptschule (AV80: OR ¼ 2.31, 95% CI 1.77–3.01;
AV85: OR ¼ 3.36, 95% CI ¼ 2.47–4.57), and in the Förderschule
(AV80: OR ¼ 2.14, 95% CI 1.13–4.04; AV85: OR ¼ 4.22, 95% CI
2.19–8.13). Participants with a single, divorced or widowed parent
had a higher prevalence of exceeding both exposure limits (AV80:
OR ¼ 1.42; 95% CI 1.12–1.80; AV85; OR ¼ 1.39, 95% CI 1.06–
1.81) in comparison to adolescents with two parents. Moreover,
boys had presented significantly higher prevalence of risky listening
compared to girls, independently of other sociodemographic factors
(AV80: OR ¼ 1.27; 95% CI 1.03–1.56; AV85: OR ¼ 1.29, 95% CI
1.01–1.64).
For 1698 of the 1971 participants, for which PMP exposure
could be defined (301 non-users and 1670 users of PMP),
audiometric data was available. Audiometric notches were observed
in 39 (2.3%) of these participants. Among participants exceeding
AV80 or AV85, slightly more audiometric notches were observed
compared to those who did not exceed these limits (Table 4).
However, no statistically significant association between prevalence
 Personal music player usage among adolescents 5
Table 2. Duration of personal music players usage and typical volume control settings in the Ohrkan study.
Duration of use (hours/week), Volume control setting as
N ¼ 1780 percentage of maximum, N ¼ 1696

10% 90%
perc. median perc. p-value 555 55–64 65–74 75-84 85-94 494 p-value
Total 1.0 6.0 22.0 41% 13% 12% 14% 5% 15%
School Public 1.0 5.0 22.0 50.01 40% 12% 13% 14% 5% 16% 0.65
Private 1.0 7.0 22.0 41% 14% 12% 14% 6% 13%
Secondary school typesa Förderschule 1.0 4.5 48.0 50.0001 52% 2% 2% 6% 0% 38% 50.0001
Hauptschule 1.3 8.0 35.0 32% 13% 9% 14% 4% 28%
Real-/Wirtschaftsschule 1.5 7.0 25.0 37% 17% 12% 16% 5% 13%
Gymnasium 1.0 5.0 15.0 46% 11% 16% 14% 6% 7%
Sex Female 1.0 6.0 22.0 0.90 45% 13% 12% 11% 5% 14% 50.001
Male 1.0 5.0 24.0 35% 13% 13% 17% 6% 16%
Age (missing ¼ 21) 13–14 years 1.0 5.0 22.0 50.0001 38% 11% 9% 21% 4% 18% 50.001
15 years 1.0 5.0 20.0 43% 14% 14% 13% 5% 11%
16 years 1.0 6.0 24.0 38% 14% 13% 14% 6% 15%
17–19 years 2.0 8.0 35.0 39% 10% 10% 10% 5% 26%
Place of birth (missing ¼ 29) Germany 1.0 5.0 21.0 50.0001 42% 13% 12% 14% 5% 14% 50.01
Abroad 2.0 10.0 35.0 32% 16% 12% 12% 3% 25%
Migration background (missing ¼ 95) None 1.0 5.0 21.0 50.0001 43% 13% 13% 13% 6% 12% 50.0001
Possible 2.0 8.0 30.0 34% 11% 15% 16% 1% 23%
Certain 2.0 8.0 30.0 34% 15% 10% 14% 5% 22%
Parental education (missing ¼ 70) Low 1.0 7.0 30.0 50.0001 32% 16% 10% 15% 5% 22% 50.0001
Medium 1.0 7.0 28.0 36% 13% 13% 15% 4% 19%
High 1.0 5.0 20.0 46% 13% 13% 13% 6% 9%
Marital status (missing ¼ 45) Single 1.0 5.0 28.0 0.02 35% 5% 15% 19% 12% 14% 50.01
Married/reg. partnership 1.0 5.0 21.0 43% 14% 12% 13% 5% 13%
Divorced 2.0 7.0 25.0 32% 12% 12% 17% 6% 21%
Widowed 1.5 5.0 18.0 43% 10% 15% 10% 5% 17%
Single parenthood (missing ¼ 41) No 1.0 5.0 21.5 0.06 42% 14% 12% 13% 5% 14% 0.02
Yes 2.0 6.0 25.0 34% 12% 12% 16% 8% 18%
a
Förderschule: special school for students who have special educational needs. Hauptschule ¼ general, vocationally oriented secondary
school for non-university bound pupils, Realschule ¼ professionally oriented secondary school, Wirtschaftsschule ¼ business school,
Gymnasium ¼ university-preparatory secondary school, high school equivalent.
N ¼ number.

Table 3. Association between sociodemographic factors and exceeding the lower exposure action value of 80 dB (A) and the upper
exposure action values of 85 dB (A), respectively, by usage of personal music players, derived from multivariate logistic regression.
Exceedance of AV80 Exceedance of AV85
Frequency Exceeding Exceeding
Sociodemographic factors N (column %) AV80 (row %) OR (95% CI) AV85 (row %) OR (95% CI)
a
Secondary school types Gymnasium 916 (48) 19.2 1.00 (Ref.) 10.7 1.00 (Ref.)
Real-/Wirtschaftsschule 490 (26) 28.8 1.58 (1.21–2.06) 19.0 1.82 (1.32–2.51)
Hauptschule 461 (24) 38.0 2.31 (1.77–3.01) 30.2 3.36 (2.47–4.57)
Förderschule 46 (2) 41.3 2.14 (1.13–4.04) 41.3 4.22 (2.19–8.13)
Sex Female 1027 (54) 24.6 1.00 (Ref.) 16.6 1.00 (Ref.)
Male 886 (46) 29.1 1.27 (1.03–1.56) 20.2 1.29 (1.01–1.64)
Age 13–14 years 264 (14) 31.1 1.00 (Ref.) 19.3 1.00 (Ref.)
15 years 835 (44) 21.7 0.74 (0.54–1.02) 14.9 0.96 (0.66–1.40)
16 years 651 (34) 29.0 1.06 (0.76–1.47) 19.7 1.28 (0.87–1.88)
17–19 years 163 (8) 36.2 1.20 (0.77–1.86) 28.2 1.55 (0.94–2.55)
Place of birth Germany 1769 (92) 26.1 1.00 (Ref.) 17.6 1.00 (Ref.)
Abroad 144 (8) 34.7 1.16 (0.79–1.71) 25.7 1.10 (0.72–1.69)
Marital status Married/reg. partnership 1473 (77) 24.3 1.00 (Ref.) 16.2 1.00 (Ref.)
Single/divorced/widowed 440 (23) 34.8 1.42 (1.12–1.80) 25.2 1.39 (1.06–1.81)

AV80 ¼ lower exposure action value of 80 dB (A), AV85 ¼ upper exposure action values of 85 dB (A), N ¼ number, OR ¼ Odds Ratio,
CI ¼ confidence interval, Ref. ¼ reference group.
a
Förderschule: special school for students who have special educational needs. Hauptschule ¼ general, vocationally oriented secondary
school for non-university bound pupils, Realschule ¼ professionally oriented secondary school, Wirtschaftsschule ¼ business school,
Gymnasium ¼ university-preparatory secondary school, high school equivalent.
6 D. Twardella et al.

Table 4. Prevalence of audiometric notches, low frequency and high frequency hearing loss, and hearing loss at 4 kHz by noise exposure
due to the usage of personal music players.
Audiometric notch LFHL HFHL HL4kHz
N N OR N OR N OR N OR
(column %) (row %) (95% CI) (row %) (95% CI) (row %) (95% CI) (row %) (95% CI)
Equivalent sound pressure
level exceeds 80 dB(A)
No 1261 (74.3) 28 (2.2) 1.00 (Ref.) 18 (1.4) 1.00 (Ref.) 43 (3.4) 1.00 (Ref.) 31 (2.5) 1.00 (Ref.)
Yes 437 (25.7) 11 (2.5) 1.14 (0.56–2.30) 7 (1.6) 1.12 (0.47–2.71) 18 (4.1) 1.22 (0.69–2.13) 12 (2.8) 1.12 (0.57–2.20)
Equivalent sound pressure
level exceeds 85 dB(A)
No 1410 (83.0) 30 (2.1) 1.00 (Ref.) 18 (1.3) 1.00 (Ref.) 46 (3.3) 1.00 (Ref.) 32 (2.3) 1.00 (Ref.)
Yes 288 (17.0) 9 (3.1) 1.48 (0.70–3.16) 7 (2.4) 1.93 (0.80–4.55) 15 (5.2) 1.63 (0.90–2.96) 11 (3.8) 1.71 (0.85–3.43)

LFHL ¼ low frequency hearing loss, HFHL ¼ high frequency hearing loss, HL4kHz ¼ hearing loss at 4 kHz, N ¼ number, OR ¼ odds ratio,
CI ¼ confidence interval, Ref. ¼ reference group.

of audiometric notches and risky listening (AV80: OR ¼ 1.14, 95%
CI 0.56–2.30; AV85: OR ¼ 1.48, 95% CI 0.70–3.16) was observed.
LFHL, HFHL and 4kHzHL were observed in 1.5%, 3.6% and 2.5%
of the 1698 participants, respectively (Table 4). Again, no
statistically significant association could be found between these
hearing loss indicators and PMP usage.
Discussion
Our study findings indicate that among participants in our study
sample, aged 15–16, high exposure to music from self-reported
PMP usage was highly prevalent. Approximately one-quarter of
participants exceeded the lower exposure value (AV80) and one-
fifth exceeded the upper exposure action value (AV85) as defined
by the European Parliament and Council (2003). High PMP
exposure was particularly prevalent among participants from
socially disadvantaged groups and among boys. However, indica-
tions of hearing loss were found in only 2.3% of our sample and not
associated with PMP usage.
The present study findings that 85% used PMPs in the previous
week are consistent with two population-based studies that have
been published since the release of the SCENIHR report, which
reported usage among adolescents of similar age groups to be 77%
and 90%, respectively (Vogel et al, 2010; Weichbold et al, 2012).
However, a study by Babisch (2009) reported lower usage (45% for
8–10-year-olds; 70% for 11–14-year-olds) which may be due to the
inclusion of younger age groups (Babisch, 2009) (for more
information on these studies and the studies cited in the following
see Supplementary Table E2 – online only).
In addition to population-based studies, in which only self-
reported data were collected, there have been three smaller studies
published in which self-reported PMP exposure data were comple-
mented with PMP output measurements. The percentage of ‘risky’
listening in those two studies which included only users was
comparably low (3.2% or 4.5%, respectively for exceedance of
AV85) (Keith et al, 2011; Sulaiman et al, 2013). Low prevalence
might have been due to selective participation of subjects with low
PMP use, since the studies were characterized by a low participation
rate of 11% (Keith et al, 2011) and restrictive exclusion criteria
(Sulaiman et al, 2013). In Sulaiman et al (2013), those students who
visited concerts or discotheques or played in a band were excluded.
However, these specific activities indicate students’ tendency to
listen to loud music, and such subjects are also likely to listen to
their PMPs at high volume or longer duration. In contrast, a separate
study from Canada, with 164 students, aged 14–17 years, estimated
that 42% of PMP users exceeded AV85 (Levesque et al, 2010).
Since typical PMP duration of use estimates are relatively
similar in these studies, differences in the percentage of risky
listening appear to arise from differences in the estimation of SPLs.
Since a 3 dB(A) increase is equivalent to doubling the PMP duration
with respect to the risk of hearing loss, it is likely, that the observed
difference in mean SPL will result in large differences in percentage
of risky listening, while minor differences in PMP duration are less
important.
Male teenagers appear to listen to music at higher volume
control settings than female teenagers. This has been observed also
in other studies (Vogel et al, 2009; Keith et al, 2011; Sulaiman et al,
2013). However, the percentage of users was higher among females
than among males, a finding which was also observed in another
German survey (Babisch, 2009).
Our findings that social disadvantage is associated with high
self-reported PMP volume, long duration of use and risky listening,
are consistent with previous studies (Babisch, 2009; Vogel et al,
2011). Further analysis of the Dutch data, by Vogel et al (2011),
indicates that this association is mediated by psychosocial correl-
ates: if in multivariate analysis psychosocial correlates are included,
associations between sociodemographic factors and risky PMP use
are no longer significant
A significant increase in audiometric notches in adolescents with
high PMP use was not observed. Other studies looking at the
influence of PMP use on audiometric results, published after the
SCENIHR report, do not consistently show an association between
PMP usage and hearing loss (see Supplementary Table E2 – online
only) (Babisch 2009; Kim et al, 2009; Martinez-Wbaldo Mdel et al,
2009; Berg & Serpanos, 2011; Henderson et al, 2011; Sekhar et al,
2011; Weichbold et al, 2012; Feder et al, 2013; Sulaiman et al,
2013). This could have been at least partly due to the chosen
exposure and outcome definition, which might have caused
measurement error and therefore biased the estimates towards the
null. Typically, the first sign of hearing loss from noise exposure is
a ‘notching’ of the audiogram at 3, 4, or 6 kHz with recovery at
8 kHz (American College of Occupational and Environmental
Medicine, 2003). The notch can be a valid indicator of possible
PMP-related hearing loss. Criteria to identify audiometric notches
were formulated by Niskar et al. (2001), and since then, have been
used in some published studies (Babisch, 2009; Henderson et al,
2011; Sekhar et al, 2011; Sulaiman et al, 2013) including Ohrkan. It
is also known that the impact of noise exposure on audiometric

thresholds depends – besides the total years of exposure – on both
the SPL as well as the weekly duration of that exposure. Using ISO
1999, one can calculate the expected frequency-specific threshold
shift given these parameters (ISO 1999, 2013). Hence the risk of
PMP-induced hearing loss can best be assessed by an exposure
measurement which incorporates both volume setting as well as the
weekly duration of PMP use, such as the noise exposure level for a
40 h week. Besides Ohrkan, only a small study from Malaysia has
used this approach in addition to the identification of audiometric
notches (Sulaiman et al, 2013). In this study also no statistically
significant association was found between the noise exposure level
and an audiometric notch.
It appears reasonable to conclude from the Ohrkan study, that in
subjects of this young age (15–16 years) the harmful consequences
of PMP usage have not yet evolved. Noise-induced hearing loss is a
slowly developing condition which takes many years to manifest.
For this reason, a follow-up of the cohort is planned to analyze the
influence of PMP use among future incident cases of audiometric
notches.
Limitations
We collected data on PMP usage from a large group of adolescents.
The main limitation of our study is a less precise estimate of SPL:
while it was not possible to conduct measurements of output levels
of subjects’ PMPs, values of SPL and the derived estimation of risk
could only be based on self-reported volume control settings. The
plausibility of this approach is backed up by a study by Portnuff
et al (2013). Here, a strong correlation between self-reported
listening duration and measured listening duration as well as
estimated SPL and measured SPL have been found. However, there
are remaining factors we could not account for which influence the
sound exposure. Firstly, the study by Portnuff et al (2011) used
North American players and due to different standards and different
regulations there can be different versions of music player devices
in different countries. The higher maximum voltage outputs of
North American players indicate that for players from Europe SPLs
might be considerably lower (Keith et al, 2008). Thus, some
systematic overestimation of the SPL is possible. Still, the PMP
exposure assessment would allow qualitative interpretation in terms
of higher and lower exposure. In addition, given a fixed volume
setting, the SPL will differ due to differences in devices, earphone
type, earphone fit and music type (Keith et al, 2008; Portnuff et al,
2011). Also the listening environment was not taken into account.
Finally, over- or underreporting of the volume setting as well as the
duration of use cannot be ruled out. We used the last week as the
time frame for PMP usage assessment since we expected this to be
easier to answer than questions relating to a longer time period.
However, for some participants the previous week of usage might
not have been representative. The potential misclassification of
exposure might have contributed to the failure to show an
association with audiometric notches. However, the plausibility of
our results is backed up by similar prevalence estimates from other
studies.
Participants were asked shortly before audiometry about noise
exposure during the last 24 hours and 14% reported to have been
exposed. However, no statistical association was found between this
exposure and the occurrence of an audiometric notch (data not
shown).
In our analysis we considered exposure to PMP usage only. A
further analysis of the same database with respect to total leisure
Personal music player usage among adolescents 7
noise exposure (including PMP exposure as well as other sources of
noise exposure such as discotheques, concerts, playing instruments
etc.) was published by Dehnert et al (2015). Also, no statistically
significant association of total leisure noise exposure and audio-
metric notches was found.
Although we were able to achieve a reasonable response rate,
data of almost half of the eligible subjects could not be retrieved.
Due to data protection matters, we did not receive adress data of the
students and thus were not able to further increase response by
individual contact, for example by sending reminder letters. No
information about these non-responders is known besides gender
and school type attended. Subjects from the ‘Hauptschule’ were
more likely to participate. Since they are also more likely to present
a higher PMP exposure, the prevalence of high PMP exposure in our
study might be overestimated.
In our study the statistical power to identify risk factors of
hearing loss is restricted by the low percentage of participants which
presented a notched audiogram. As discussed in Twardella et al.
(2013) the reason for the comparably low prevalence in our study
remains unknown. Higher prevalence in other studies might be due
to methodological differences. Schlauch and Carney (2011) argued
that the high prevalence of audiometric notches in NHANES (about
16% in a comparable age group) would be an artefact caused by
systematic measurement errors in particular due to the use of a
specific type of headphone in audiometry.
Conclusion
In our survey among 2143 adolescents mostly aged 15 or 16 years, a
large proportion reported using their PMP for long durations and
such high volume, that the equivalent noise exposure exceeds noise
at work limits effective in the European Union (AV80 and AV85).
Only a few participants were affected by an audiometric notch and
no evidence for causation by PMP use was found. It may be possible
that hearing loss was not observed due to the young age group of the
cohort and that continued exposure would result in noise-induced
hearing loss. A preventative measure may focus on lowering volume
settings rather than on duration of usage. For example, a small
reduction of mean SPL of 3 dB(A) appears to be easier to achieve
than to cut the listening duration in half, but both have the same
relevance for risk of hearing loss. Since SPLs are not displayed on
PMPs, some general guidance on safe volume control settings,
possibly in combination with allowable duration of use, may be most
useful, an approach used by the Swiss Accident Insurance Fund
SUVA (Hohmann, 2009). However, existing variability in maximal
output due to varying limits integrated in devices, currently make
general recommendations difficult. Furthermore, users have possi-
bilities to set their own limits for many devices or annul limits which
have recently been implemented. Therefore, recommendations could
take a stepwise approach: Either set or accept a volume limit or
consider time limitations for the higher volume levels. As high
volume control settings and risky PMP use are more prevalent
among socially disadvantaged adolescents and among males, these
groups should be particularly focused on.
Acknowledgements
This work was supported by the Bavarian Ministry for the
Environment and Health. We would like to thank Angelika
Zirngibl for data management and support in data analysis.
8 D. Twardella et al.
Declaration of interest: The authors report no conflicts of interest.
This study was funded by the Bavarian Ministry for the
Environment and Health. The funding source was not involved in
study design, in the collection, analysis and interpretation of data, in
the writing of the report, or in the decision to submit the article for
publication.
Ethical approval
The study was approved by the Ethics Committee of the University
Hospital of Regensburg.
Presentation at professional meetings
Ulla Verdugo-Raab, Dorothee Twardella, Carmelo Perez Alvarez,
Thomas Steffens, Angelika Zirngibl, Gabriele Bolte, Hermann
Fromme: Die Ohrkan-Studie: Nutzung von tragbaren
Musikabspielgeräten und Hörverluste. 7. Congress of the German
Society for Epidemiology (DGEpi), Regensburg, Germany, 26–29
September 2012.
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