Journal of the American Society of Hypertension 12(2) (2018) 71–79

Research Article
Occupational noise exposure and hypertension: the
Dongfeng-Tongji Cohort Study
Dongming Wang, MDa,b,c,d, Min Zhou, MDa,b, Wenzhen Li, MDe, Weijia Kong, MDf,
Zhichao Wang, MDf, Yanjun Guo, MDa,b, Xiaomin Zhang, MDa,b, Meian He, MDa,b,
Huan Guo, MDa,b, and Weihong Chen, MD, PhDa,b,*
a
Department of Occupational & Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science
and Technology, Wuhan, Hubei, China;
b
Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of
Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, Hubei, China;
c
Department of Occupational Health, Wuhan Prevention and Treatment Center for Occupational Diseases, Wuhan, Hubei, China;
d
Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan,
Hubei, China;
e
Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science
and Technology, Wuhan, Hubei, China; and
f
Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan,
Hubei, China
Manuscript received August 8, 2017 and accepted November 7, 2017

Abstract

The association between occupational noise exposure and hypertension is unclear. We aimed to explore the association in a
Chinese population and to summarize our findings with previous published articles. The cross-sectional study included
22,450 participants from Dongfeng-Tongji Cohort Study. In a subsample of 10,636 subjects, we assessed the association be-
tween hearing loss and hypertension. For the meta-analysis, we searched PubMed and EMBASE until April 2017, and the
pooled odds ratio (OR) was combined using a random effect model. Compared with participants without occupational noise
exposure, the risk of hypertension was significantly higher for noise exposure duration
20 (OR ¼ 1.09, 95% confidence
interval [CI] ¼ 1.00–1.18). In the sex-specific analysis, the association was only significantly pronounced in males
(OR ¼ 1.16, 95% CI ¼ 1.03–1.31), but not in females (OR ¼ 1.01, 95% CI ¼ 0.88–1.14). In the subsample analyses, hearing
loss, which was an indicator for exposure to loud noise, was associated with a higher risk of hypertension, especially for
participants who were bilateral hearing loss (OR ¼ 1.39, 95% CI ¼ 1.24–1.54). In the meta-analysis, the pooled OR for
the association between occupational noise exposure and hypertension was 1.25 (95% CI ¼ 1.10–1.42). On the basis of
an indicator for exposure to occupational noise, the cross-sectional study and meta-analysis identified occupational noise
exposure as a potential risk factor for increased hypertension risk. J Am Soc Hypertens 2018;12(2):71–79. Ó 2017
American Society of Hypertension. All rights reserved.
Keywords: Hearing loss; hypertension; occupational noise exposure.

The study was supported by the National 111 Project in China
(No.B12004), Innovative Research Team in University of Ministry
of Education of China (No.IRT1246), the Fundamental Research
Funds for the Central Universities, HUST2016YXZD044 and
Open project of Hubei Province Key Laboratory of Occupational
Hazard Identification and Control (OHIC2017Y05). The funder
did not play any role in study design; in the collection, analysis,
and interpretation of data; in the writing of the report; nor in the
preparation, review, or approval of the article.
Conflicts of interest: None.
*Corresponding author: Weihong Chen, MD, PhD, Department
of Occupational and Environmental Health, School of Public
Health, Tongji Medical College, Huazhong University of Science
and Technology, No. 13 Hangkong Road, Wuhan, 430030, P. R.
China. Tel/Fax: þ86 27 83691677.
E-mail: wchen@mails.tjmu.edu.cn

1933-1711/$ - see front matter Ó 2017 American Society of Hypertension. All rights reserved.
https://doi.org/10.1016/j.jash.2017.11.001
72 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79
Introduction
Occupational noise is a common occupational hazard
around the world. It is reported that approximately 600
million workers worldwide are exposed to occupational
noise.1 Long-term exposure to high-level noise is associ-
ated with a series of adverse health effects, including
noise-induced hearing loss,2,3 sleeping disorders,4 and psy-
chological stress.5 Recently, noise is increasingly suggested
as an indicator for cardiovascular events, including coro-
nary heart disease,6 myocardial infarction,7 and stroke.8
Many epidemiologic studies have explored the association
between occupational noise and hypertension, including
community and occupational settings.9,10 However, the
results regarding occupational noise were less consistent.11
Significant positive associations were revealed in both
cross-sectional and cohort studies,12,13 but the inverse results
were also found in other studies.14,15 For instance, Chang
et al12 found long-term exposure to occupational noise of
higher than 85 dB(A) may increase males’ blood pressure
levels in a 10-year prospective cohort study. However, Sto-
kholm et al14 reported no increase in risk of hypertension
for those exposed to occupational noise above 80 dB(A)
within a 7-year prospective cohort study. The inconsistent
findings might be owing to the differences in study design,
noise assessment, and potential confounders. Besides, some
studies were limited by a small sample size or a short time
of follow-up.
Hearing loss is the change in the hearing threshold at
different frequencies, and it is considered as one of the well-
known consequences of exposure to high-level noise.2 The
severity of hearing loss is related with the intensity and dura-
tion of occupational noise.16 Persistent damage to hair cells
and hearing conduction nerves induced by long-term exposure
to relatively high level of occupational noise is thought to be a
key reason for hearing loss.17 Thus, it could be served as an
indicator for personal exposure to occupational noise.
Given the limitations and inconsistent findings from pre-
vious studies, we conducted a cross-sectional study to
examine the effect of occupational noise exposure and hear-
ing loss on hypertension in a large middle-aged and older
Chinese population. Meanwhile, we also conducted a
meta-analysis to summarize the evidence on association
of occupational noise exposure and hypertension.
Methods
Study Population
The study included 22,450 participants from the
Dongfeng-Tongji Cohort Study, which has been reported
elsewhere.18 In brief, all the participants were retired em-
ployees from Dongfeng Motor Corporation (DMC), each
participant has a unique medical insurance card number
in the DMC’s health care service system. The cohort study
was established in 2008 and was followed up for every
5 years. Finally, a total of 27,009 retired employees
completed baseline questionnaires and medical examina-
tions. And 5 years later, 25,978 individuals (96.2%)
completed the follow-up until October 2013. Among
them, 22,450 individuals who finished the follow-up with
complete data of occupational history information and all
the covariates at baseline (10,097 males and 12,353 fe-
males) were included in the analysis of occupational noise
exposure and hypertension. In 2013, 11,513 participants
from these 22,450 subjects underwent the audiometric ex-
amination. Both valid audiometric data and hypertension
data were available for 10,636 of these 11,513 subjects.
Noise Exposure Assessment
The occupational history information was self-reported
and obtained via questionnaire, which contains personal
data on employment and variables about the work, such
as the corporation, the job title, and the duration of each
job title. Occupational hazards monitoring was conducted
every year in Dongfeng corporations by professional occu-
pational health physicians. The industrial noise level for
each job title at workplace came from the company records
which were measured by qualified industrial hygienists.
Occupational noise level was evaluated by a sound analyzer
(3M QUEST SoundPro DL, USA) according to the occupa-
tional health standard in China (GBZ/T 189.8-2007 Mea-
surement of Physical agents in Workplace Part 8: Noise).
And then the equivalent continuous A-weighted sound pres-
sure level was normalized to an 8-hour per day (LEX, 8h).
Noise exposure levels for workplaces outside of DMC
were determined through the job description. They were esti-
mated using monitoring data from similar job titles in DMC
companies or according to experience of industrial hygien-
ists. The occupational noise exposure was defined as exposed
to the normalized continuous A-weighted sound pressure
level equivalent to an eight-hour per day of
80 dB(A)
(LEX, 8h
80 dB(A)) for at least a year. Besides, years of
occupational noise exposure were divided into four groups:
0, 1w<10, 10 to w<20,
20.
Audiometry Examination and Ascertainment of
Hearing Loss
Each subject was given a general physical and an otologic
examination first. Then pure-tone audiometry was performed
in a sound-isolated room with a calibrated pure-tone audiom-
eter (Micro-CD21) by certified audiologists. Air conduction
thresholds were determined for each ear at 0.5, 1, 2, 4, and
8 kHz across an intensity range of 10 to 120 dB. The
non-responses were coded as missing values. Hearing loss
was defined as a pure-tone average of
25 dB at 0.5, 1, 2,
and 4 kHz in either ear.19,20 We also divided hearing loss
into exclusive unilateral and bilateral categories.
 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79
Ascertainment of Hypertension
Participants sat 10 minutes before blood pressure was
measured using mercury sphygmomanometers and the par-
ticipants were in a sitting position. Each participant was
measured by three times, and all measurements and medi-
cal examinations were performed by trained nurses or
physicians. Individuals were defined as hypertension if
they met one of the following standards: (1) self-reported
physician diagnosis of hypertension; (2) self-reported
current use of antihypertensive medication, the Anatomical
Therapeutic Chemical codes for antihypertensive medica-
tion were C02A, C02B, C02C, C02D, C02K, and C02L;
(3) mean value of systolic blood pressure >140 mm Hg
and/or diastolic blood pressure >90 mm Hg measured in
medical examination.
Covariates
Information on sociodemographic characteristics (sex
and age), shift work, lifestyle, tea consumption, coffee con-
sumption, family history of hypertension, physical activity,
and life stress were collected through a questionnaire by
face-to-face interview with trained interviewers. Individ-
uals smoking at least one cigarette per day for more than
half a year were defined as current smokers, and those
who drink at least one time per week for more than half
a year were defined as current drinkers. Physical activity
was defined as regularly exercised more than 20 min/d
over the last 6 months. Life stress was defined as those
who feel upset, nervous, or even despair of daily life equal
or more than 3 times per week. Body mass index (BMI)
was calculated as weight in kilograms divided by the square
of the height in meters and was divided into four categories:
<18.5, 18.5 to w<25, 25 to w<28, and
28.
Blood lipids, including triglycerides (TGs), total choles-
terol (TC), high-density lipoprotein cholesterol (HDL-C),
and low-density lipoprotein cholesterol (LDL-C) were
tested at the hospital’s laboratory.
Ethical Approval
The study was approved by the Ethics and Human Sub-
ject Committee of Tongji Medical College, and Dongfeng
General Hospital, DMC. The written informed consents
were obtained from all the participants before the study
enrollment.
Statistical Analysis
Sociodemographic characteristic of participants was re-
ported as mean (standard deviation) for continuous vari-
ables and as number (percentages) for categorical
variables. Logistic regressions were performed to evaluate
the association of occupational noise exposure and hyper-
tension. Moreover, we conducted stratified analysis
73
between different types of hearing loss and hypertension
in the subgroup subjects, as hearing loss could be consid-
ered as an indicator for long-term exposure to occupational
noise.20,21 We chose covariates according to evidence from
published literature.14,22 Covariates included age, sex, BMI,
waist, shift work, smoking status, drinking status, family
history of hypertension, tea consumption, coffee consump-
tion, physical activity, life stress, diabetes, TGs, TC,
HDL-C, and LDL-C. All statistical analyses were per-
formed using SAS version 9.2 software (SAS Institute
Inc, Cary, NC, USA). The statistical tests were two sided,
and significance was set at P < .05.
Meta-analysis of Observational Studies on the
Association Between Occupational Noise
Exposure and Hypertension
We conducted a systematic review and meta-analysis in
accordance with the Meta-analysis Of Observational
Studies in Epidemiology guidelines.23 Literature were
searched from PubMed (MEDLINE) and EMBASE up to
April 2017, with the following criteria: (1) the study design
was observational study; (2) the exposure variable was
occupational noise exposure and the outcome was hyper-
tension; (3) the risk estimates with 95% confidence inter-
vals (CIs) were reported; and (4) original population
study. Studies were included with the longest follow-up
duration if the population were reported more than once.
Data were extracted independently by two authors
(D.M.W. and W.Z.L.). The lowest level of occupational
noise exposure was defined as ‘‘no occupational noise
exposure,’’ other categories were combined as ‘‘occupa-
tional noise exposure’’ and was calculated as a common
odds ratio (OR) using a random effects model.24 When
several models were fitted, we extracted models with
most confounding variables. Any articles stratified by
gender were treated as two separate reports. The overall
pooled OR was conducted by using a random effects model
for the main analysis. Newcastle–Ottawa Quality Assess-
ment Scale was used to assess the quality of cohort
studies25 and Agency for Healthcare Research and Quality
was used for cross-sectional studies.26 We examined the
heterogeneity with Q test and I2 statistic. To explore the
sources of heterogeneity, sensitivity analyses and subgroup
analyses were also conducted. All analyses were performed
with Stata version 12 (Stata Corp), and all tests were two
sided with a significance level of 0.05.
Results
Descriptive
Baseline characteristics of the 22,450 participants
included in the analysis were reported by hypertension cat-
egories (Table 1). Among them, 55.0% of participants were
74 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79

females and 66.8% aged >60 years. Overall, 8587 individ-
uals (38.2%) reported to expose to occupational noise dur-
ing their work period, and the prevalence of hypertension
among all participants was 52.6% (11,799/22,450), 55.8%
(5630/10,097) for males, and 49.9% (6169/12,353) for fe-
males. We observed pronounced differences in hyperten-
sion prevalence by demographic characteristics.
Prevalence of hypertension was higher among men, indi-
viduals aged >60 years, having a family history of hyper-
tension, individuals who were overweight and obese, and
the longest noise exposure duration group. Individuals
exposed to occupational noise for
20 years were more in-
clined to having hypertension.
Occupational Noise Exposure and Hypertension
The ORs and 95% CIs for the effect of occupational
noise exposure on hypertension were presented in
Table 2. Compared with participants not exposed to occu-
pational noise, the risk of hypertension was significantly
higher in the group of
20 years noise exposure
(OR ¼ 1.09, 95% CI ¼ 1.00–1.18), after adjusting for

Table 1
Baseline characteristics of participants by hypertension categories
Variables Total Hypertension Normotension P Value
(N ¼ 22,450) (N ¼ 11,799) (N ¼ 10,651)
Age (y, mean  SD) 62.6  7.8 64.2  7.4 60.9  7.8 <.001
Age (y) <.001
<60 7472 (33.3) 2996 (25.4) 4476 (42.0)
60 to w<70 13,396 (59.7) 7748 (65.7) 5648 (53.0)

70 1582 (7.1) 1055 (8.9) 527 (5.0)
Sex <.001
Male 10,097 (45.0) 5630 (47.7) 4467 (41.9)
Female 12,353 (55.0) 6169 (52.3) 6184 (58.1)
Shift work, n (%) 10,703 (47.7) 5500 (46.6) 5203 (48.9) .001
Current smokers, n (%) 4006 (17.8) 1999 (16.9) 2007 (18.8) <.001
Current drinkers, n (%) 4686 (20.9) 2413 (20.5) 2273 (21.3) .10
Family history of hypertension, n (%) 4963 (22.1) 3312 (28.1) 1651 (15.5) <.001
Physical activity, n (%) 19,982 (89.0) 10,527 (89.2) 9455 (88.8) .28
Life stress, n (%) 10,758 (47.9) 5873 (49.8) 4885 (45.9) <.001
Waist (cm, mean  SD) 83.3  9.5 85.5  9.4 80.9  9.0 <.001
Tea consumption, n (%) 8207 (36.6) 4364 (37.0) 3843 (36.1) .16
Coffee consumption, n (%) 444 (2.0) 161 (1.4) 283 (2.7) <.001
Diabetes, n (%) 2688 (12.0) 1856 (15.8) 832 (7.8) <.001
TC, mmol/L 5.17  0.97 5.13  0.96 5.21  0.99 <.001
TG, mmol/L 1.46  1.15 1.32  1.08 1.59  1.20 <.001
HDL-C, mmol/L 1.44  0.41 1.47  0.40 1.41  0.41 <.001
LDL-C, mmol/L 3.02  0.84 2.99  0.83 3.05  0.85 <.001
BMI <.001
<18.5 604 (2.7) 192 (1.6) 412 (3.9)
18.5 to w<25 12,305 (54.8) 5557 (47.1) 6748 (63.3)
25w<28 6282 (28.0) 3749 (31.8) 2533 (23.8)

28 3259 (14.5) 2301 (19.5) 958 (9.0)
Occupational noise exposure, n (%) .003
No 13,863 (61.8) 7349 (62.3) 6514 (61.2)
1  y <10 1979 (8.8) 979 (8.3) 1000 (9.4)
10  y <20 2529 (11.3) 1283 (10.9) 1246 (11.7)

20 y 4079 (18.2) 2188 (18.5) 1891 (17.7)
Hearing loss, n (%)* <.001
No 2383 (22.4) 908 (17.6) 1475 (26.9)
Unilateral 1705 801 (15.5) 904 (16.5)
Bilateral 6548 3449 (66.9) 3099 (56.6)
Either 8253 (77.6) 4250 (82.4) 4003 (73.1)
BMI, body mass index; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; SD, standard devia-
tion; TC, total cholesterol; TG, triglyceride.
* N ¼ 10,636 for audiometric data and hypertension data.
 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79 75

Table 2
Odds ratios (95% confidence intervals) of hypertension by occupational noise exposure
Occupational Noise Exposure N Model 1* Model 2y Model 3z
Total
0 13,863 ref ref ref
1  y <10 1979 0.86 (0.78–0.94) 0.92 (0.84–1.02) 0.90 (0.79–1.01)
10  y <20 2529 0.91 (0.84–1.00) 0.96 (0.88–1.06) 0.94 (0.85–1.05)

20 y 4079 1.01 (0.94–1.08) 1.03 (0.96–1.11) 1.09 (1.00–1.18)
Male
0 5700 ref ref ref
1  y <10 857 0.89 (0.77–1.02) 0.89 (0.77–1.04) 0.84 (0.71–1.02)
10  y <20 953 0.95 (0.83–1.09) 0.95 (0.82–1.11) 0.92 (0.76–1.10)

20 y 2587 1.02 (0.93–1.12) 1.07 (0.97–1.18) 1.16 (1.03–1.31)
Female
0 8163 ref ref ref
1  y <10 1122 0.83 (0.73–0.93) 0.96 (0.84–1.09) 0.92 (0.81–1.06)
10  y <20 1576 0.90 (0.81–1.00) 0.97 (0.86–1.08) 0.96 (0.85–1.08)

20 y 1492 0.88 (0.79–0.98) 0.99 (0.88–1.11) 1.01 (0.88–1.14)
* Unadjusted.
y
Adjusted for age and body mass index.
z
Adjusted for age, sex, shift work, body mass index, waist, current smoking status (yes, no), current drinking status (yes, no), family
history of hypertension (yes, no), tea consumption (yes, no), coffee consumption (yes, no), physical activity (yes, no), life stress (yes,
no), diabetes (yes, no), total cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein.

potential confounders. Stratified analyses revealed that the
association between the longest noise exposure duration
group (
20 years) and hypertension was more pronounced
in males (OR ¼ 1.16, 95% CI ¼ 1.03–1.31), not in females
(OR ¼ 1.01, 95% CI ¼ 0.88–1.14).
Hearing Loss and Hypertension
In our different types of hearing loss study subgroup, par-
ticipants with hearing loss had a significantly higher risk of
hypertension, compared with those with normal hearing
(Table 3). The ORs and CIs were 1.23 (1.07–1.41), 1.39
(1.24–1.54), and 1.34 (1.20–1.50) for unilateral, bilateral,
and either ear hearing loss, respectively. In the stratified anal-
ysis, bilateral ear hearing loss got the highest risk of hyper-
tension in all the subgroups (OR: 1.29–1.58). Moreover, the
association between bilateral hearing loss and hypertension
was particularly strong for participants who were females,
aged
60 years, and exposed to occupational noise.
the random effects model. Overall, the polled OR of hyper-
tension for occupational noise exposure was 1.25 (95%
CI ¼ 1.10–1.42, I2 ¼ 87.6%, Pheterogeneity < .001).
Subgroup analysis by location, sex, study design, refer-
ence noise exposure group, number of participants, whether
controlling for BMI was conducted to test the stability of
the results (Table S3). The associations between occupa-
tional noise exposure and the risk of hypertension were
similar in most subgroup analyses. But it implied that
different noise exposure reference group might be a
possible source of heterogeneity. In addition, sensitivity
analysis excluded a single study, in turn, did not alter
the combined OR, with a range from 1.16 (95%
CI ¼ 1.05–1.29) to 1.31 (95% CI ¼ 1.13–1.51; Figure S1).
Visual inspection of funnel plots failed to identify sub-
stantial asymmetry (Figure S2). No evidence of publication
bias among these studies was found by Begg’s rank corre-
lation test and Egger’s linear regression test (Begg’s test
Z ¼ 1.71, P ¼ .09; Egger’s test t ¼ 0.75, P ¼ .47).

Systematic Review and Meta-analysis Discussion

Ten reports from nine articles in the present study were
included in the meta-analysis.12–15,27–31 The main informa-
tion of the included studies was summarized in Tables S1
and S2. Among all nine studies, six studies were cross-
sectional design13,15,27–29,31 and three studies were cohort
design.12,14,30 Occupational noise ascertainment in all the
studies was measured by noise meter except for one
article.28 The sample size ranged from 415 to 145,190,
with a total of 181,700. Figure 1 revealed the result from
In this large population-based study of middle-aged
and older Chinese adults, we observed a positive relation-
ship between occupational noise exposure and hyperten-
sion. Those exposed to industrial noise in the longest
duration group (
20 years) was associated with a 9% in-
crease in hypertension risk, after adjusting for other risk
factors and comorbidities. The findings were consistent
with part of previous articles.32,33 Sbihi et al indicated
that sawmill workers exposed to occupational noise
76 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79

Table 3
Odds ratios (95% confidence intervals) of hypertension by different types of hearing loss
Type of Hearing Loss N Model 1* Model 2y Model 3z
Total
No 2383 ref ref ref
Unilateral 1705 1.44 (1.27–1.64) 1.29 (1.13–1.46) 1.23 (1.07–1.41)
Bilateral 6548 1.81 (1.64–1.99) 1.41 (1.28–1.57) 1.39 (1.24–1.54)
Either 8253 1.73 (1.57–1.89) 1.38 (1.25–1.52) 1.34 (1.20–1.50)
Age (y)
<60
No 1436 ref ref ref
Unilateral 702 1.31 (1.08–1.58) 1.30 (1.08–1.57) 1.26 (1.02–1.55)
Bilateral 1414 1.46 (1.25–1.70) 1.43 (1.22–1.67) 1.32 (1.13–1.56)
Either 2116 1.41 (1.22–1.62) 1.38 (1.20–1.60) 1.30 (1.12–1.51)

60
No 947 ref ref ref
Unilateral 1003 1.24 (1.04–1.48) 1.26 (1.05–1.50) 1.19 (0.97–1.45)
Bilateral 5143 1.37 (1.20–1.58) 1.41 (1.23–1.62) 1.42 (1.21–1.65)
Either 6137 1.35 (1.18–1.55) 1.38 (1.21–1.59) 1.38 (1.17–1.61)
Sex
Male
No 641 ref ref ref
Unilateral 667 1.26 (1.02–1.57) 1.22 (0.98–1.51) 1.10 (0.85–1.42)
Bilateral 3513 1.47 (1.24–1.75) 1.36 (1.14–1.61) 1.34 (1.10–1.64)
Either 4180 1.44 (1.22–1.70) 1.33 (1.12–1.58) 1.30 (1.05–1.59)
Female
No 1742 ref ref ref
Unilateral 1038 1.48 (1.26–1.73) 1.32 (1.12–1.54) 1.28 (1.07–1.52)
Bilateral 3035 1.92 (1.71–2.17) 1.42 (1.25–1.62) 1.37 (1.19–1.56)
Either 4073 1.80 (1.60–2.02) 1.39 (1.23–1.57) 1.33 (1.17–1.53)
Occupational noise exposure
No 811 ref ref ref
Unilateral 595 1.39 (1.19–1.62) 1.21 (1.03–1.42) 1.31 (1.03–1.67)
Bilateral 2318 1.75 (1.55–1.97) 1.35 (1.19–1.53) 1.58 (1.31–1.92)
Either 2913 1.67 (1.49–1.87) 1.31 (1.16–1.48) 1.51 (1.24–1.82)
No occupational noise exposure
No 1572 ref ref ref
Unilateral 1110 1.56 (1.26–1.94) 1.44 (1.16–1.80) 1.20 (1.01–1.42)
Bilateral 4230 1.95 (1.65–2.30) 1.55 (1.30–1.85) 1.29 (1.12–1.49)
Either 5340 1.86 (1.58–2.19) 1.52 (1.28–1.81) 1.26 (1.11–1.44)
* Unadjusted.
y
Adjusted for age and sex.
z
Adjusted for age, sex, shift work, body mass index, waist, current smoking status (yes, no), current drinking status (yes, no), family
history of hypertension (yes, no), tea consumption (yes, no), coffee consumption (yes, no), physical activity (yes, no), life stress (yes,
no), diabetes (yes, no), total cholesterol, triglyceride, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.

85 dBA for more than 30 years had a significantly
higher risk of hypertension in a retrospective cohort
study with a sample size of 10,872.34 Moreover, the re-
sults of the present study benefited from larger sample
size and were based on models adjusting for individual
risk factors, which were not conducted in previous study.
The divergent outcomes among some studies may be
because of the different definition and category of occu-
pational noise, exposure duration, study design, exposure
assessment, and sample size across different studies.
In the sex-specific estimates, we found the association
with a 16% increase in hypertension risk among males.
However, the relationship was not statistically significant
among female population. The gender difference may be
related with different jobs between males and females.
Although exposed to occupational noise environment, fe-
male workers may experience relatively lower noise envi-
ronment, when compared with male workers.
As we all know, occupational noise was one of the major
causes of hearing loss,35 thus we use hearing loss as an
 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79
Figure 1. The relationship between occupational noise exposure and risk of hypertension.
indicator to reflect the cumulative exposure of occupational
noise. Meanwhile, we also found it was significantly asso-
ciated with hypertension, and the bilateral ear hearing loss
got the highest risk. It could be explained that occupational
noise was usually supposed to bilateral and fairly symmet-
rical.20,36 Besides, the association between bilateral hearing
loss and hypertension was more evident in the subgroup
subjects who exposed to occupational noise, which could
verify the result of occupational noise and hypertension
in our study. Besides, unilateral hearing loss was also asso-
ciated with higher risk of hypertension. We thought it may
be related to the position of the work, one side face or
closer to noise source, except for ear trauma or disease.
We also searched the previously published studies and
combined the results with our study. It showed that occupa-
tional noise exposure was associated with an increased risk
of hypertension when compared with no occupational noise
exposure. The meta-analysis including 181,700 partici-
pants, substantially greater than previously published
studies, provides additional validity to our results. Besides,
the association remained significant in most subgroup ana-
lyses, such as the subgroup of different study design,
different number of participants, controlling for potential
confounders or not, and different noise exposure reference
group.
The mechanisms that underlie these associations are
complex. Several potential biological mechanisms may
contribute to the association of occupational noise exposure
and hypertension. Noise exposure, a psychosocial stressor,
77
could activate the hypothalamic-pituitary-adrenal and sym-
pathetic nervous systems and then increase the level of
cortisol, adrenaline, and noradrenaline, which could result
in the change of blood pressure.37 Moreover, it could also
affect the endocrine systems to disturb metabolic and hor-
monal status of the human body, then increase the blood
pressure, change hormones levels or other biochemical
levels (such as blood glucose and lipids), resulting in the
occurrence of hypertension.38,39
The present study has several strengths. First, it revealed
the independent cross-sectional study and selected a sub-
sample subject with pure-tone audiometry to confirm the
results. Second, our study combined results with previously
published articles simultaneously, which could benefit from
larger sample size. In addition, this is the first meta-analysis
to quantify the strength of association between occupa-
tional noise exposure and hypertension, and we included
studies with a mean quality score of 7.1, which could
also increase the reliability of the findings.
Some limitations should also be acknowledged. First, the
cross-sectional design could restrict the evidence of causal
inferences. Second, although a range of confounders were
adjusted in our study, some other factors were still not
included, such as leisure time noise exposure and individual
information on the use of hearing protection, which were
also reported to be associated with hypertension or noise
exposure level. Third, occupational noise exposure outside
of DMC was only based on the work history as reported by
the workers or the job description. Fourth, different
78 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79
definitions for occupational noise exposure were used
across studies, which might introduce heterogeneity into
the results. Finally, the limited information provided in
the included studies precluded the possibility of a dose-
response analysis.
In summary, the cross-sectional study and meta-analysis
showed a significant increase in hypertension risk among
occupational noise exposure workers. Studies with larger
sample sizes and longer follow-up times are warranted to
probe the potential mechanisms and to establish causality.
Acknowledgments
The contributions of all the participants, staffs of the
Health Examination Center of the Dongfeng Central Hospi-
tal and the Medical Insurance Center of DMC, and all
members of study team are greatly acknowledged.
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Appendix

Meta-analysis random-effects estimates (exponential form)

Study ommited
Attaichi

Gan

Souza

Chen

Chang

Liu Chiu

Liu jing

Inoue

Stokholm male

Stokholm female

This study male

This study female

1.05 1.10 1.25 1.42 1.53

Figure S1. Sensitivity analyses for occupational noise expo-

sure and risk of hypertension.

Begg's funnel plot with pseudo 95% confidence limits

1
log[or]

-1
0 .2 .4
s.e. of: log[or]

Figure S2. Funnel plot of occupational noise exposure and risk

of hypertension.
 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79 79.e2

Table S1
Characteristics of studies included in meta-analysis
First Author Publication Year Country Study Design Sex of Population No of Participants
Attaichi et al 2013 Iran Cross-sectional Male 502
Gan et al 2010 US Cross-sectional Male and female 6307
Souza et al 2015 Brazil Cross-sectional Male and female 1729
Chen et al 2017 China Cross-sectional Male and female 2789
Chang et al 2013 Taiwan Cohort Male 578
Liu Chiu et al 2016 Taiwan Cohort Male and female 1002
Liu Jing et al 2016 China Cross-sectional Male and female 738
Inoue et al 2005 Japan Cross-sectional Male 415
Stokholm et al (male) 2013 Danish Cohort Male 108,402
Stokholm et al (female) 2013 Danish Cohort Female 36,788
This study (male) 2017 China Cross-sectional Male 10,097
This study (female) 2017 China Cross-sectional Female 12,353
 79.e3
Table S2
Outcome and covariates of studies included in meta-analysis
First Author Noise Ascertainment Case Ascertainment Noise and Relative Risk Covariates in Fully Quality
(95% CI) Adjusted Model Assessment
Attaichi et al Measured by using a Measured by physicians with 61–72, 1.0 (reference); 77–83.5, 4.38 Age, work of duration, BMI, smoking, 7
CEL-440 sound a standard mercury (1.27–10.53); 86.5–97, 9.43 (2.81– dietary salt, regular exercise, shift
level meter sphygmomanometer 23.46); 88–102, 14.22 (3.21–40.84) working, nature of job, and family
history of hypertension

D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79
Gan et al Questionnaire Self-reported or measured 0, 1.0 (reference); 0–0.3 y, 1.16 (0.83– Age, sex, ethnicity, BMI, educational 6
using a mercury 1.63); 0.4–1.5 y, 1.29 (0.80–2.07); level, physical activity, smoking and
sphygmomanometer 1.6–18.8 y, 1.09 (0.79–1.51) diabetes, annual family income,
pack-years of smoking, passive
smoking in the workplace or at
home, alcohol drinking, waist
circumference, and total cholesterol
Souza et al Measured using a Self-reported or measured by 75, 1.0 (reference); 75–85, 1.56 Age, gender, BMI 7
digital audio physicians (1.13–2.17);
85, 1.58 (1.10–2.26)
dosimeter
Chen et al Determined by a Self-reported or measured by 80,1.0 (reference); 80–90, 1.11 (0.71– Age, smoking, and drinking status 7
noise statistical physicians 1.72); 90–95, 1.99 (1.38–2.87); 95–
analyzer 100, 2.26 (1.54–3.33);
100, 2.83
(1.87–4.28)
Chang et al Measured using Self-reported or measured by <80, 1.0 (reference); 80–<85, 1.75 Age, BMI, employment duration, 8
a sound analyzer nurse with an automated (1.09–2.81);
85, 1.93 (1.15–3.22) alcohol intake, cigarette use,
sphygmomanometer education level, regular exercise
Liu Chiu et al Measured using a Self-reported or measured by <75, 1.0 (reference); 75–79, 0.98 Age, sex, triglyceride level, the use of 8
sound level meter physicians (0.68–1.42);
80, 1.38 (1.02–1.85) hearing-protective devices, BMI,
smoking status, alcohol
consumption, regular exercise, and
family history of hypertension
Liu Jing et al Measured using a Measured by physicians 85, 1.0 (reference); >85, 1.52 (1.07– Age 6
sound pressure with an automated 2.15)
noise meter sphygmomanometer
Inoue et al Measured using a Self-reported or measured by 75, 1.0 (reference); 92, 0.48 (0.28– Age, BMI, smoking, alcohol drinking, 7
sound pressure physicians 0.81) exercise, diet, and family history of
noise meter hypertension
Stokholm et al Measured by personal Self-reported or a hospital <75, 1.0 (reference); 75–79, 1.03 Age, socioeconomic status, calendar 8
(male) dosimeters discharge diagnosis of (0.90–1.18); 80–84, 1.00 (0.88– year, and employment status
hypertension 1.14); 85–89, 1.04 (0.91–1.18); 90–
94, 1.06 (0.92–1.22); 95–99, 0.98
(0.84–1.15); >100, 0.99 (0.75–1.31)
(continued)
Table S2 (continued )
First Author Noise Ascertainment Case Ascertainment Noise and Relative Risk Covariates in Fully Quality
(95% CI) Adjusted Model Assessment
Stokholm et al 75, 1.0 (reference); 75–79, 1.03 (0.89–
(female) 1.18); 80–84, 1.10 (0.96–1.25); 85–
89, 1.12 (0.97–1.28); 90–94, 1.21
(1.03–1.42); 95–99, 1.29 (1.03–1.60)
This study Came from the Self-reported <80, 1.0 Age, sex, shift work, BMI, waist, 7

(male) company records
which were measured
This study by qualified institutions,
(female) or consulted with
local industrial
hygienists
BMI, body mass index; CI, confidence interval.
D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79
or measured (reference);
80, current smoking status, current
by physicians 1.05 (0.95–1.16) drinking status, family history of
<80, 1.0 (reference);
80, 0.97 (0.89– hypertension, tea consumption,
1.05) coffee consumption, physical
activity, life stress

79.e4
79.e5 D. Wang et al. / Journal of the American Society of Hypertension 12(2) (2018) 71–79

Table S3
Stratified analyses on associations of occupational noise exposure and risk of hypertension
Variables No. RR 95% CI I2 (%) P*
Location
Asia 8 1.39 1.08–1.79 90.60 <.001
Europe 2 1.07 0.97–1.17 74.70 <.002
USA 2 1.33 0.98–1.81 72.70 .056
Sex
Male 2 1.03 0.97–1.09 0 .631
Female 2 1.04 0.91–1.20 85.80 .008
Combined 8 1.55 1.11–2.15 87 <.001
Study design
Cross-sectional 8 1.35 1.07–1.70 90.70 <.001
Cohort 4 1.14 1.00–1.30 77.50 .004
Reference group
<75 dB(A) 5 1.15 1.01–1.30 78.00 .003
<80/85 dB(A) 4 1.31 1.06–1.62 86.00 <.001
Others 3 1.6 0.47–5.38 95.50 <.001
No. of participants
5000 7 1.64 1.10–2.43 87.50 <.001
>5000 5 1.05 0.99–1.11 53.70 .071
Controlling family history of hypertension in models
Yes 5 1.19 0.89–1.60 91.80 <.001
No 7 1.31 1.14–1.51 82.80 <.001
Controlling BMI in models
Yes 7 1.3 1.03–1.62 90.10 <.001
No 5 1.2 1.03–1.40 83.20 <.001
BMI, body mass index; CI, confidence interval; RR, relative risk.
P* for heterogeneity.