ARTICLE IN PRESS

Effects of Early Smoking Habits on Young Adult Female

Voices in Greece
*,†Dionysios Tafiadis, *,†Eugenia I. Toki, ‡Kevin J. Miller, and *,†Nausica Ziavra, *†Ioannina, Greece, and
‡Seward, Nebraska

Summary: Cigarette use is a preventable cause of mortality and diseases. The World Health Organization states that
Europe and especially Greece has the highest occurrence of smoking among adults. The prevalence of smoking among
women in Greece was estimated to be over 30% in 2012. Smoking is a risk factor for many diseases. Studies have
demonstrated the association between smoking and laryngeal pathologies as well as changes in voice characteristics.
The purpose of this study was to estimate the effect of early smoking habit on young adult female voices and if they
perceive any vocal changes using two assessment methods. The Voice Handicap Index and the acoustic analyses of
voice measurements were used, with both serving as mini-assessment protocols. Two hundred and ten young females
(110 smokers and 100 nonsmokers) attending the Technological Educational Institute of Epirus in the School of Health
and Welfare were included. Statistically significant increases for physical and total scores of the Voice Handicap Index
were found in the smokers group (P < 0.05). Significant changes were observed for the acoustic parameters between
smoker and nonsmoker groups. The results of this study indicated observable signs of change in the voice acoustic
characteristics of young adults with early smoking habits.
Key Words: Acoustics–Computerized voice analysis–Smoking–Voice characteristics–Voice Handicap Index.

INTRODUCTION and perceptual analyses36–40; and (3) self-evaluation question-

Voice disorders result from changes in the voice mechanism,1,2 naires, such as Voice Handicap Index (VHI).41–49
leading to vocal inefficiency.3 Previous studies indicated that the Although previous research recognized the effect of smoking
prevalence of voice disorders is approximately 9%,4 with women on voice characteristics, no study to this point has estimated the
having a higher occurrence of voice disorders.5 influence of early smoking on voice characteristics. The purpose
Epidemiologic studies also reported a positive association of of this research was to estimate the effect of an early smoking
smoking with approximately 40 causes of morbidity and habit on VHI scores and acoustic voice parameters for young
mortality,6–8 and a high prevalence of tobacco use in adults.9–12 adult females.
According to the World Health Organization,9 Greece has the
highest incidence of tobacco smoking at 42.4%. Another study MATERIALS AND METHODS
also estimated that cigarette smoking for women in Greece ex-
Participants
ceeded 30%.10
Two hundred and ten young adult females (110 smokers and 110
Smoking is a high-risk factor influencing voice and its
nonsmokers) were recruited from the School of Health and
characteristics.13–15 The relationship between smoking and changes
Welfare at Technological Educational Institute of Epirus. Par-
in the larynx leading to voice disorders is evident.16–18 It has been
ticipants had no history of laryngeal or respiratory system
well documented that lesions of the larynx linked to smoking
disorders 2 weeks before enrollment and those who did were
habits could result in vocal polyps,17 Reinke edema,19 vocal fold
excluded. In addition, participants who reported symptoms cor-
carcinomas,18,20,21 chronic inflammation, erythema, or irritation
related to gastroesophageal reflux disease or laryngopharyngeal
of laryngeal mucosa.21–23 Chai et al24 found that smoking affects
reflux, or drug or alcohol abuse were not included. Smokers were
perceptual, acoustic, and aerodynamic performance. Further-
considered those who smoked at least two cigarettes daily for
more, changes were found in fundamental frequency (F0),25–27
at least one consecutive year prior to the study. Nonsmokers were
jitter, and shimmer.12,13
those who never smoked.
People, including smokers, having voice symptoms can be
evaluated with various methods. These methods are composed
of: (1) imaging techniques28–33; (2) aerodynamic,33–36 acoustic, Data collection
All participants completed the Greek version of VHI.49 It con-
Accepted for publication March 21, 2017.
sists of 30 items, divided into three domains: emotional (VHI-
Conflict of interest: All authors declare no conflicts of interest in this paper. E), physical (VHI-P), and functional (VHI-F). Voice sampling
From the *Laboratory of Audiology, Neurootology and Neurosciences, Department of
Speech & Language Therapy, Technological Educational Institute of Epirus, Ioannina, Greece;
was obtained in a quiet room (<40 dB)50 in accordance with the
†Laboratory of New Approaches in Communication Disorders, Department of Speech & National Center for Voice and Speech recommendations.51,52 The
Language Therapy, Technological Educational Institute of Epirus, Ioannina, Greece; and
the ‡Department of Special Education, Concordia University, Seward, Nebraska.
recordings were done using a Mai CM—903 electret condens-
Address correspondence and reprint requests to Eugenia I. Toki, Laboratory of Audiology, er meeting microphone (Tiger Electronics Inc., North Reading,
Department of Speech & Language Therapy, Technological Educational Institute of Epirus,
4th Km Ioaninna, Athens Road, P.C. GR455 00 Ioannina, Greece. E-mail: toki@ioa.teiep.gr
MA) placed at least 10 cm away from each participant’s mouth.50
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ Participants were allowed to rehearse before their final mea-
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
surement. They were asked to sustain /a/ and /e/ for at least 5
http://dx.doi.org/10.1016/j.jvoice.2017.03.012 seconds. Schutte and Seidner50 recommended sustaining /a/, /i/,
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2017

TABLE 1.
Comparison of VHI Scores Between Female Smokers and Nonsmokers
Smokers Nonsmokers
VHI Median (IQR) Median (IQR) P Level
Total 32.56 (14.00–57.00) 25.93 (16.00–36.00) 0.004*
Functional 7.91 (4.00–14.00) 7.55 (5.00–13.00) 0.369
Physical 8.16 (4.00–12.00) 7.35 (5.00–12.00) 0.005*
Emotional 8.04 (4.00–12.00) 7.70 (5.00–11.00) 0.101
* Significant at P < 0.05.
Abbreviations: IQR, interquartile range; VHI, Voice Handicap Index.

and /u/ to obtain measurements for voice. Voice analysis was
performed with Dr. Speech software, version 4.0 (Tiger Elec-
tronics Inc.). The parameters of habitual F0 (Hz), mean F0 (Hz),
% jitter, % shimmer, harmonic-to-noise-ratio (HNR) (dB), and
intensity (dB) were measured and analyzed.53,54
Statistical analysis
Normally distributed variables (for sustained voicing of /e/, mean
F0 and habitual F0) are expressed as mean ± standard devia-
tion, whereas variables with skewed distribution (VHI-T, VHI-
F, VHI-P, and VHI-E; for the sustained voicing of /a/ sound, the
variable of habitual F0 [Hz], mean F0 [Hz], % shimmer, % jitter,
HNR [dB], and intensity [dB]; and for the sustained voicing of
/e/ sound, % shimmer, % jitter, HNR [dB], and intensity [dB])
are expressed as median (interquartile range). A Student t test
was computed for normally distributed variables. The Mann-
Whitney U test was used for the comparison of continuous and
non-normally distributed variables. All reported P values are two-
tailed. Statistical significance was set at P < 0.05 and analysis
was conducted using SPSS statistical software (version 19.0, IBM
Corp., Armonk, NY).
RESULTS
The participants’ mean age was 22.12 years (SD: ±2.33) and ranged
from 19 to 34 years. The mean age of the smokers’ subgroup
was 22.21 years (SD: 2.38) and for the nonsmokers it was 22.09
(SD: 2.29). The average years of smoking was 2.16 (SD: ±1.29)
and the number of cigarettes smoked daily was 13.19 (SD: 6.65).
For smokers, the VHI-T was 32.56 (SD: ±10.29), VHI-F was
7.91 (SD: ±4.62), VHI-P was 8.16 (SD: ±4.51), and VHI-E was
8.04 (SD: ±4.12). For nonsmokers, VHI-T was 25.93 (SD:
±12.23), VHI-F was 7.55 (SD: ±4.32), VHI-P was 7.35 (SD:
±4.32), and VHI-E was 7.70 (SD: ±4.13).
Significant changes were noted in the VHI total score between
smokers (median = 32.56) and nonsmokers (median = 25.39),
U = 4504.50, P < 0.05; and VHI physical score between smokers
(median = 8.16) and nonsmokers (median = 7.35), U = 4316.00,
P = 0.05. No statistically significant changes were observed for
the VHI functional and emotional domains (Table 1).
A comparison of the median for non-normally distributed voice
acoustic characteristics between smoking and nonsmoking females
was considered. There was a significant difference for the ha-
bitual F0 of smokers (median = 205.97) and nonsmokers
(mean = 227.22), U = 2526.00, P = 0.000. Similarly, for the sus-
tained voicing of /a/, there was a statistical difference for the %
shimmer between smokers (median = 0.68) and nonsmokers
(median = 0.50), U = 4213.00, P = 0.003; and the % jitter between
smokers (median = 0.21) and nonsmokers (median = 0.18),
U = 4878.00, P = 0.000. There was no statistical significance com-
puted for mean F0, HNR, and intensity (Table 2).
For sustained voicing of /e/, a Student t test was calculated
to compare voice acoustic characteristic means, which fol-
lowed a normal distribution, between smokers and nonsmokers.
There was a significant difference for mean F0, t (198) = −4.123,
P < 0.01; and habitual F0, t (198) = −3.997, P < 0.01 (Table 3).
For non-normal distributed data, a Mann-Whitney U test was
used to compare medians between smokers and nonsmokers, for
sustained voicing of /e/. There was a significant difference for
% shimmer of smokers (median = 0.57) and nonsmokers
(mean = 0.37), U = 4468.50, P = 0.00. There were no signifi-

TABLE 2.
Comparison of Acoustic Parameters Between Female Smokers and Nonsmokers (Sustained Voicing of /a/)
Smokers Nonsmokers
Median (IQR) Median (IQR) P Level
Habitual F0 (Hz) 205.97 (201.75–215.05) 227.22 (210.02–243.26) 0.000*
Mean F0 (Hz) 205.92 (201.81–215.54) 228.48 (210.22–228.48) 0.156
% Shimmer 0.68 (0.18–0.21) 0.50 (0.23–0.77) 0.003*
% Jitter 0.21 (0.18–0.24) 0.20 (0.15–0.23) 0.000*
HNR (dB) 24.65 (21.87–25.92) 24.94 (22.53–27.03) 0.164
Intensity (dB) 62.54 (58.00–66.00) 60.00 (57.00–66.00) 0.421
* Significant at P < 0.05.
Abbreviations: F0, fundamental frequency; HNR, harmonic-to-noise-ratio; IQR, interquartile range.
 ARTICLE IN PRESS
Dionysios Tafiadis, et al Early Smoking Effects on Greek Young Adult Female Voices
TABLE 3.
Comparison of Acoustic Parameters Between Female Smokers and Nonsmokers (Sustained Voicing of /e/)
Smokers
Mean (SD)
† Habitual F0 (Hz) 241.42 (±28.23)
† Mean F0 (Hz) 241.27 (±28.28)
Smokers
Median (IQR)
% Shimmer 0.57 (0.29–0.96)
% Jitter 0.23 (0.17–0.43)
HNR (dB) 25.30 (23.46–27.48)
Intensity (dB) 60.00 (58.00–66.00)
* Significant at P < 0.05.
†
Student t test results.
Abbreviations: F0, fundamental frequency; HNR, harmonic-to-noise-ratio; IQR, interquartile range; SD, standard deviation.
cant differences for the rest of the acoustic measurements
(Table 3).
DISCUSSION
The purpose of the present study was to determine the effects
of smoking on voice parameters and VHI scores. The results of
this study revealed changes in habitual F0, mean F0, shimmer,
jitter, VHI-T, and VHI-P scores of female smokers who did not
report any vocal symptoms.
Studies have reported varied results regarding tobacco use on
quality of life when using VHI. Pinar and colleagues55 ob-
served significant increases of the VHI total score and physical
subscale scores for male smokers; the same trend was ob-
served for female smokers in this study. On the contrary,
Wiskirska-Woznica and Wojnowski56 stated that smoking habits
do not affect VHI measures in older adults. Specifically, the VHI
functional and emotional subscale scores were higher in smokers
than in nonsmokers, which contrasts with this study’s results.
Moreover, VHI could be used as a screening tool for early
smokers for better monitoring of how they perceive their voice
status over time. Consequently, a rise in the VHI score and its
domain could be a good indicator for an early referencing to a
voice specialist.
Female smokers had significantly higher scores for VHI-T and
VHI-P compared to the control group. Also, VHI-T median score
was 32.56 and was similar to Helidoni et al’s research49 on Greek
patients with voice disorders and dysphonic patients from other
countries.57,58 Probably, young female smokers managed to per-
ceive the negative effect of their smoking habit on voice after
filling out VHI, according to some participants’ statements. Also,
it may have aided our participants in better understanding the
implications of smoking on their voices, similar to Jacobson et al’s
research on dysphonic patients who understood the impact that
their voice disorder had on daily living.42 Perhaps VHI scores
could help females with early smoking habits in Greece to monitor
their voice and work toward cessation of smoking.
In this study, voice F0 changes were observed. These changes
demonstrated the effect of early smoking on fundamental
3
Nonsmokers
Mean (SD) P Level
256.91 (±25.97) 0.000*
256.21 (±25.93) 0.000*
Nonsmokers
Median (IQR) P Level
0.37 (0.21–0.92) 0.000*
0.22 (0.15–0.43) 0.019
25.65 (24.14–27.40) 0.437
60.00 (58.00–66.00) 0.753
frequency values, similar to previous research.27,59 Significant low-
ering of the F0 in female smokers compared to nonsmokers was
reported, which was also observed in this study.12,13,60,61 Another
factor potentially affecting the lowering of the F0 is the change
in vocal fold mass because of smoking habits.13,23,62,63 Like-
wise, the effect on F0 is probably the combination of years
smoking and the number of cigarettes smoked daily.13,63,64 Sim-
ilarly, statistically significant differences on perturbation
parameters (shimmer and jitter) were observed in the smoking
subgroup and these results are similar to previous studies.12,13
These findings could mean that young adult female smokers in
Greece may develop a smoking-related voice disorder in the
future.
CONCLUSIONS
This study examined the changes of voice acoustic character-
istics using the VHI and voice analysis with Dr. Speech software
in young adult female smokers in Greece. Results indicated the
following: (1) early smoking habits influence specific voice acous-
tic characteristic measurements (F0, jitter, and shimmer) as well
as the VHI-T and VHI-P scores; (ii) VHI may be as sensitive
as a screening-monitoring tool for early smokers; and (iii) the
VHI and acoustic analyses of voice could serve as a screening
protocol.
Limitations to this study include using only young adult females
who were recruited and not using a multidimensional evalua-
tion. Suggestions for future research include the assessment of
different smoking populations on a longitudinal basis to better
understand the relationship between voice changes and early cig-
arette smoking.
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