Logopedics Phoniatrics Vocology.

2005; 30: 185
/191

LPV FORUM

Health and voice quality in smokers: An exploratory investigation

ISABEL GUIMARÃES & EVELYN ABBERTON

Escola Superior de Saúde do Alcoitão, Alcabideche, Portugal, and University College London, UK

Abstract
Thirty-two adults (20 smokers and 12 non-smokers) were examined to determine the effects of cigarette smoking on health
(diseases and larynx histology), on fundamental frequency (regularity and jitter) and stress level. The examination consisted
of nasovideostroboscopy analysis, history case, electrolaryngography assessment for different task performance and self-
assessment of stress. Although not statistically different, results indicate that smokers in comparison to non-smokers show:
1) slightly more health problems; 2) histological larynx changes; 3) a higher level of stress; 4) a lower mean F0 for all speech
tasks. A statistically significant difference for percentage jitter was found according to voice status for: 1) vowel [a] (the
group with voice problems show higher levels of jitter than both groups without voice problems); 2) vowel [i] (the smokers
with voice problems show higher levels of jitter than the smokers without voice problems).

Key words: ELG (electrolaryngography) assessment, self-assessment of stress, smoking, voice

Introduction individuals who smoke more than 35 cigarettes a day

Thousands of studies a year corroborate the relation-
ship between tobacco use in its various forms,
especially cigarette smoking, and a whole series of
diseases, more than twenty (1,2). Among all those
diseases it has been noted that smokers have a higher
risk of: 1) respiratory disease (emphysema, bronchi-
tis and cancer) (3,4); 2) sinusitis due to a significant
impact on the mucociliary clearance in the nose,
resulting in the stasis of secretions (2,5) and; 3)
gastroesophageal disease (6).
Tobacco smoking has been, also, identified as one
of the main determinants of changes on the larynx
histology. It is highly detrimental to the mucous
membrane and epithelial lining of the larynx, basi-
cally because of its irritant effects, especially on the
free vibrating edge of the vocal folds, and reduction
of the mucociliar movement causing dehydration
(7
/13). As a consequence of irritation, persistent
cough and throat clearing (13,14) also contribute to
mucus concentration in the superficial layer of the
vocal fold. With continued smoking these tissues are
predisposed to injury (e.g., hypaeremia, oedema,
haemorrhage) and/or necrosis (e.g., keratinization,
hyperplasia, squamous cell metaplasia). Moreover,
present a seven-fold higher risk of laryngeal cancer
(2,9,15). Feijó et al. (2) found a higher prevalence of
histological changes (metaplasia, hyperplasia) in
autopsied smokers than non-smokers. Also, Muller
and Krohn (1980, cited by (2)) found in 148
autopsies that 83.3% of the non-smokers had a
normal epithelium while for the ‘heavy’ smokers the
estimates dropped to 30.6%. Gilbert and Weismer
(7) found vocal fold thickening in 87% of smokers as
compared with 7% of non-smokers in the age range
30
/54 years old. Prout et al. (15) found that 90% of
squamous cell carcinomas of the larynx occurred in
persons 40 years and older who had a history of
smoking habits, or who were smokers at the time of
diagnosis.
Subsequent to these laryngeal histological varia-
tions, changes in the vibratory pattern of the vocal
folds may occur (10), resulting in lowering of the
voice fundamental frequency (F0) and higher levels
of irregularity (jitter) in smokers in comparison to
non-smokers (7
/9,16). Published data are presented
in Table I.
The F0 trends (Table I) were dependent on the
vocal behaviour used and gender. For example,

Correspondence: Isabel Guimarães PhD, Lecturer, Escola Superior de Saúde do Alcoitão, Rua Conde Barão, Alcoitão, 2649-506 Alcabideche, Portugal. Fax:
/351 21 4607459. E-mail: iguimaraes@essa.pt

ISSN 1401-5439 print/ISSN 1651-2022 online # 2005 Taylor & Francis

DOI: 10.1080/14015430500294114
186 I. Guimarães & E. Abberton
Table I. Mean F0 data (in Hertz) for smokers and non-smokers without voice complaints.
Female non-smokers
Gilbert and Weismer (1974) (7)
Sorensen and Horii (1982) (9)
Fernandez Liesa et al. (1999) (23)
Female smokers
Gilbert and Weismer (1974) (7)
Sorensen and Horii (1982) (9)
Damborenea Tajada et al. (1999) (16)
Male non-smokers
Sorensen and Horii (1982) (9)
Fernandez Liesa et al. (1999) (23)
Male smokers
Sorensen and Horii (1982) (9)
Damborenea Tajada et al. (1999) (16)
smokers showed a statistically significant lower F0
during: 1) sustained phonation in Damborenea
Tajada et al. (16); 2) reading in Gilbert and Weismer
(7), and in the male group in Sorensen and Horii
(9); 3) spontaneous speech for the male group in
Sorensen and Horii (9). Although the trend, a lower
F0 for the smokers, was still evident, it did not reach
a statistically significant difference between smokers
and non-smokers in: 1) sustained phonation for
Sorensen and Horii (9); 2) during oral reading for
the female group in Sorensen and Horii (9); 3)
during spontaneous speech for the female group
(7,9).
Percentage jitter data for smokers and no-smokers
without voice complaints is still scarce. The typical
range of values for jitter percentage accepted for
‘normal’ sustained phonation is between 0.5% and
1% (19,20). Damborenea Tajada et al. (16) indi-
cated in both genders a statistically significant higher
mean (0.27; SD /0.19) for smokers than for non-
smokers (0.23; SD /0.13) for the vowel [a] in spite
the fact that jitter percentage is within the accepted
range for ‘normal’ sustained phonation.
Laryngeal and voice tobacco-related risks are
also related to the duration of the habit and
quantity consumed as well as associated habits
such as alcohol consumption and voice use
(2,4,9,10,15,16). Murphy and Doyle (10) found a
F0 rise (about 18 Hz; 1.63 ST) for two smokers after
40 hours of non-smoking, whilst the two control age
and gender matched non-smoker speakers did not
show a rise in their F0 for all the speech tasks used
(sustained vowels, reading and speech). Dedivitis et
al. (6) analysed 57 ex-alcoholics aged between 28
and 81 years old and with an average age of 49 years.
All had a smoking habit that varied between 5 and 60
years with a mode of 20 cigarettes a day. General
health data revealed 13 with digestive problems and
14 with respiratory changes. The majority, 48
[i] [u] [a] Reading Speech
182.8
205.5 204.6 198.8 188.4 186.5
201
163.8
203.5 200.8 195.5 184.8 182.7
184.9
125.6 123.2 110.9 120.7 116
128.6
120.2 119.2 114.1 109.2 105.7
114.9
ex-alcoholics, had no voice complaint although 35
had sore throat or foreign body sensation and 7
complained of pain.
Evidence also suggests that nicotine dependence
may develop more readily in stressful environments
(19). According to Hébert (20) smoking may
reduce anxiety and other negative feelings in
stressful situations by inhibiting right brain infor-
mation processing and improving left-brain pro-
blem solving. Higher levels of anxiety/depression
symptoms and negative life events according to
Billings and Moos (19) are more common in
smokers, especially in heavy smokers than non-
smokers. However nicotine effects appear to be
dependent on other factors as well, including the
amount of nicotine, the manner of administration,
the gender and history of mood disturbance of the
smoker, and whether alcohol or caffeine are
ingested while smoking.
Statistically significant differences in stress, using
the Social Readjustment Rating Scale, (SRRS) (21)
were found in 60 university students with the
smokers showing a higher level of stress than the
non-smokers (154.2 versus 110.1). The smoking
habit existed for a mean of 5 years and the mean
number of cigarettes a day was 10 (22).
Unfortunately, scientific evidence on the effect of
smoking on the larynx and voice quality is still scarce
(7,9,10,16,23). The inconsistencies found may be
due to certain methodological constraints that may
limit the validity of the findings, namely: 1) data was
obtained from only a occupational group (e.g.,
university students) (20) or several occupational
groups (e.g., secretaries, housewives, nurses and
students) (8); 2) identification of smoking habit
(years, quantity consumed) is not presented; 3)
laryngostroboscopic examination was not performed
(8,9); 4) the vocal behaviour studied is usually
sustained vowels (7,9,16).

This study attempted to control some of the
methodological problems by using control groups
of smokers and non-smokers matched by gender and
approximate age without voice problems and a group
of smokers with voice problems. It was undertaken
to determine if smokers have: 1) a higher number of
health problems and laryngeal histological changes;
2) a higher level of stress; 3) a lower F0 during
different speech tasks performance; 4) higher level of
F0 irregularity (jitter).
Materials and methods
Subjects
Thirty-two adults (20 smokers and 12 non-smokers)
were selected from a voice database (24). Subjects
were matched by number, age and gender. The age
range of non-smokers range was 20
/51 years with a
mean of 32 years. The age range of smokers with
voice problems was 27
/51 years with a mean age of
37 years. The majority had more than 12 years of
education and were in employment (between 100%
and 67%) and a few used their voice on a profes-
sional basis (between 8% and 17%).
Subjects were divided into subgroups on the
basis of their voice condition and smoking habits.
A subject was considered to have a voice problem
if he/she had a voice problem on the day of the
assessment or a history of voice complaints for
which the speech and language therapist (SLT)
and the ENT surgeon found corroborative evi-
dence (24).
The non-smoker group included subjects with no
smoking history or who had had a smoking history
but had quit smoking for at least five consecutive
years before the voice assessment (9). All subjects in
the non-smoker group had a non-smoking history
with an exception of a subject who quit smoking ten
years ago. The active smokers were the subjects that
were smokers at the time of the voice assessment.
Table II shows the characteristics of smokers accord-
ing to smoking habits.
Table II. Smokers’ habits according to voice status.
Without voice
problems n /12 problems n/8
Years of smoking habit:
Mean9/standard 14.39/9.6
deviation (SD)
Range 3
/32
Number of cigarettes per day:
Mean9/standard 7.49/5.2
deviation (SD)
Range 1
/20
Health and voice quality in smokers 187
As might be seen in Table II subjects with voice
problems have a longer-standing habit of smoking
and a higher quantity of cigarettes a day than the
smokers without voice problems.
Experimental method
The individual assessments included case history
questionnaire, nasovideostroboscopic examination
by an ENT surgeon, electrolaryngographic (ELG)
recordings using a portable laryngograph processor
(Laryngograph Ltd) and a portable battery powered
digital audio tape (Sony TCD
/D8) and a self-rating
of psychological stress (21).
The phonatory tasks were:
Sustained vowels. The subject had to sustain, for at
least five seconds, three vowels [a, i, u] at a
comfortable pitch and loudness level. The subject
was asked to repeat the productions if they were
considered to be too short or too irregular.
Oral reading. The subject was required to read aloud
(with comfortable pitch, loudness and speaking rate)
a standard passage (Arthur the Rat) of three
minutes’ duration.
Conversation. The subject was engaged in a con-
versation (to elicit spontaneous speech) started by
the researcher asking open questions that required
extended answers ‘What did you do yesterday?’,
‘How did you come to the hospital?’, in order to
obtain a minimum of three minutes’ duration for
analysis.
The self-rating of stress involved the use of the
Social Readjustment Rating Scale (SRRS) (21), a
43-item scale of major life events either indicative of
the life style of the individual (personal) or of
occurrences involving the individual (family, work
and financial). The emphasis is on major life events
that could force the organism into illness or mala-
daptive behaviour, and not on psychological mean-
ing, emotion or social desirability. The SRRS assigns
Voice points (through the use of the magnitude estimation
technique) to stressful events on the basis of
standards from the average individual. For example,
19.39/7.6 under 150 (no life crisis) between 151 and 199
(slight life crisis), between 200 and 299 (moderate
10
/30
life crisis) and above 300 (intense life crisis) (21).
219/14.1 Subjects were instructed to indicate those items
which they have experienced in the last six months
5
/40
(24).
188 I. Guimarães & E. Abberton

Analyses 250

All speech data were digitized at 44,100 times per

second, stored and analysed with Speech Studio
from Laryngograph Ltd. Statistical analysis was 200
performed with SPSS (Statistical Package for
the Social Sciences) version 12. Whenever possible,

Total level of stress

a non-parametric test for independent groups 150
(Mann-Whitney) was used, with a p -value of
B/0.05 considered significant.
100

Results
Health history
Smokers (without or with voice problems) in com-
parison to non-smokers show a slightly higher
percentage of nose abnormalities (45% versus
42%), nasopharyngeal abnormalities (15% versus
0%), hypopharynx abnormalities (40% versus 25%),
respiratory diseases (10% versus 8%) and reflux
disease (15% versus 8%).
Smokers also show a slightly higher level of
dehydration considering that they reported a lower
level of maximum daily water intake (between 1.5
/2
litres versus 3 litres) and a higher maximum daily
consumption of cups of coffee (between four to six,
versus three). Nevertheless, alcohol consumption
(daily and occasionally) is slightly lower in smokers
than non-smokers (67% versus 55%).
Laryngeal histological changes
As shown in Table III the presence of laryngeal
histological changes seems to be, overall, related to
heavier and longer consumption of tobacco.
Level of stress
As might also be seen in Figure 1, the distribution of
stress values, upper quartile (top of the box) and the
50
0
Non-smokers Smokers without voice Smokers with voice
problems problems
Figure 1. Results of the self-assessment of stress.
lower quartile (bottom of the box), is higher in the
smokers either with or without voice problems than
in the non-smokers. The distribution of the stress
values approaches ‘normality’ (seen by the location
of the thick bar across the interior of the box, in
Figure 1, that represents the median) in the smokers
without voice problems. Skewness (indicated by an
eccentric location of the median within the boxes in
Figure 1) is higher for the smokers with voice
problems (SD /88.7) than that for the non-smokers
(SD /60.3).
The total mean level of stress for the non-smokers
was lower (62.8) than the total mean level of stress in
the smokers without voice problems (98.8) and in
the smokers with voice problems (111.6). Never-
theless, the difference did not reach statistical
significance (p /0.05).

Table III. Laryngeal histology versus smoking history.

Without voice problems Voice problems

Non-smokers Smokers Smokers

n/12 n /12 Years of smoking Number of cigarettes n/8 Years of smoking Number of cigarettes

Healthy larynx 12 9 [5
/13] [1
/10]
/
/
/

Minor abnormalities
/ 3 [5
/19] [1
/17]
/
/
/
Polyp
/
/
/
/ 1 10 5
Cronic laryngitis
/
/
/
/ 1 10 10
Cyst
/
/
/
/ 2 [14; 20] [8; 15]
Reinke’s oedema
/
/
/
/ 2 [20; 23] [30; 40]
Nodules
/
/
/
/ 1 27 20
Sulcus vocalis
/
/
/
/ 1 30 40
 Health and voice quality in smokers 189

Fundamental frequency Rosas and Baptista (4) and Dedivitis et al. (6)
(respectively 23% and 24%). The differences may
General results of the F0 analyses for all the
be related to the size of the sample, smaller in the
phonatory tasks are presented in Table IV.
present study (32 subjects) than in the other two
In every speech task, the F0 values for the
(107 and 57 subjects).
smokers, either with or without voice problems, are
A lower percentage of gastroesophageal problems
lower than the corresponding values for the non-
in smokers (15%) was found than that cited by
smokers. Also, within smokers, subjects with voice
Dedivitis et al. (6) which was 25%. Several questions
problems show a lower F0 during sustained phona-
may arise, firstly Dedivitis et al. (6) report digestive
tion than smokers without voice problems, with
problems which may include problems others than
an exception on the vowel [u] in the female group.
gastroesophageal problems; secondly, their popula-
The statistical analyses revealed that the difference
tion were ex-alcoholics which was not the case in the
between the groups was not statistically significant,
present study; and finally, the mean age of the
for all speech tasks (p /0.05).
subjects, 49 years old in Dedivitis et al. (6) is higher
than in the present study (32 and 37 years old).
Jitter (fundamental frequency perturbation)
General results of the jitter analyses for all the Laryngeal histological changes
phonatory tasks are presented in Table V.
Data in the present study suggests that histological
Results show that smokers with voice problems
changes of the larynx are related to the history of
present the highest jitter values for all speech tasks,
smoking (years and number of cigarettes a day) as
but the smokers without voice problems present
might be seen in Table III. This finding seems to
lower jitter values than non-smokers.
confirm the scientific evidence of the detrimental
A non-statistical significance (p /0.05) was found
effects of tobacco on laryngeal histological structure
for all jitter measurements according to the smoking
(2,7
/11,15).
habit. Nevertheless, the smokers with voice pro-
blems show a statistically significant higher level of
jitter for the vowel [a] than the non-smokers (U / Level of stress
1.0, p /0.01) and than the smokers without voice
Data found in this study show that all subjects are
problems (U /11.5, p /0.007). The smokers with
within the group categorized by Holmes and Rahe
voice problems show a statistically significant higher
(21) as ‘no life crisis’ (a total under 150). Although
level of jitter for the vowel [i] than the smokers
not statistically significant, results in this study
without voice problems (U /19.5, p/0.043).
corroborate the evidence that smokers present
higher levels of stress than non-smokers (19,22).
Discussion The fact that the results of Rodrigues (22) reached a
statistically significance, while those of the present
Health changes
study did not, may be related to the size of
In a general sense smokers show a slightly higher population studied in her study, which was 60.
percentage of health changes in spite of the fact that
they are not heavy smokers, which corroborates the
Fundamental frequency
fact that cigarette smoking carries a higher risk of
disease (2,4). In a general sense F0 values found in the present
The percentage of respiratory disease found in the study are slightly higher than those published (see
present study (10%) is smaller than that found by Table I). The results may be explained on the basis
Table IV. F0 (mean9/standard deviation)

Without voice problems Voice problems

Non-smokers (n / 12) Smokers (n/ 12) Smokers (n / 8)

Females (n/ 8) Males (n / 4) Females (n / 8) Males (n/ 4) Females (n / 6) Males (n/ 2)

[a] 231.59/28.7 116.99/14.4 189.69/25.6 118.59/11.1 188.19/22.0 105.79/36.2

[i] 231.49/24 137.69/33.2 206.89/16.3 124.29/5.6 200.09/61.6 120.89/52.5
[u] 230.69/22.7 118.09/14.3 211.19/17.3 120.69/9.8 213.59/37.2 109.29/41.9
Oral reading 201.49/22.1 114.69/21.1 189.09/16.7 107.19/7.6 159.29/27.9 103.69/33.3
Conversation 195.19/21.9 122.59/8.8 182.69/10.8 111.29/6.6 149.09/31.9 99.59/33.9
190 I. Guimarães & E. Abberton
Table V. Jitter percentage (mean9/standard deviation).
Without voice problems Voice problems
Non-smokers (n/12) Smokers (n/ 12) Smokers (n / 8)
[a] 0.529/0.18 0.409/0.13 1.19/0.70
[i] 0.479/0.21 0.389/0.18 0.869/0.56
[u] 0.519/0.28 0.559/0.38 0.739/0.49
of some identifiable methodological differences
between studies such as the analysis method: 1)
systems more than 20 years old (7,9); 2) different
type of analysis such as ELG (electrolaryngographic)
in the present study and acoustic in Damborenea
Tajada et al. (16); 3) different analysis systems used,
such as Speech Studio from Laryngograph in the
present study and Dr. Speech from Tiger Electronics
in Damborenea Tajada et al. (16).
Results suggest that cigarette smoking has a pitch-
lowering effect for all the speech tasks although
differences did not reach statistical significance.
These findings are in agreement with Sorensen and
Horii (9) for sustained vowel production in both
genders and for oral reading and spontaneous speech
in the female group. It is also in agreement with the
results of Gilbert and Weismer (7) for spontaneous
speech.
A possible explanation for the fact that speech
tasks did not reach statistical significance is perhaps
because values are based on a small number and
inclusion of more subjects may provide significance
in the results.
A F0 lowering effect is also seen between smokers
(with and without voice problems) with the smokers
with voice problems showing a lower F0 than the
ones without voice problems (as shown in Table IV).
This finding is in agreement with the published
evidence that smokers with a heavier and longer
duration of consumption will show worse voice
problems (7,9,16)
Jitter (fundamental frequency perturbation)
All the percentage values gathered in this study for
subjects without voice problems (non-smokers and
smokers) are between 0.38% and 0.55%, accepted
by the researchers (17,18) for ‘normal’ sustained
phonations.
Although within the ‘normal’ limits, the evidence
of higher jitter magnitudes in non-smokers without
voice problems than smokers without voice problems
suggests that irregularity may be due to unknown
factors other than smoking effect. For example, non-
smokers in comparison to smokers reported a higher
percentage of alcohol consumption (67% versus
55%).
In the present study, jitter measures were not
sensitive to the main effect of smoking habit. The
lack of significance may be attributable to a low
number of years of smoking habit and a non-
considerable percentage of consumed of cigarettes
per day (see Table II).
Nevertheless, statistically significant differences
were found between the groups according to voice
status, with the group with voice problems showing
higher jitter percentage for the vowel [a] than
subjects without voice problems.
Statistically significant different jitter measure-
ments for the vowel [i] were found between the
smokers according to larynx health status. Also,
the highest jitter magnitudes were found in smo-
kers with voice problems, and the possible major
explanation arises from the fact they are ‘heavy’
smokers and consequently with laryngeal histolo-
gical changes.
Conclusions
This study investigated the effects of cigarette
smoking on health and voice quality. Although the
differences are not statistically significant, smokers,
in comparison to non-smokers, show: 1) slightly
more health problems; 2) histological larynx
changes; 3i) a higher level of stress; 4) a lower
mean F0 for all speech tasks.
Results also indicate a statistically significant
difference between the groups, according to the:
1) smoking habit and larynx status for jitter
percentage of vowel [i]: smokers with voice pro-
blems present a significantly higher irregularity
than smokers without voice problems; 2) voice
status (without and with problems) for jitter
percentage of vowel [a]: the group with voice
problems presents a significantly higher irregularity
than the group without voice problems (non-
smokers and smokers).
Care should be taken in the interpretation and
generalization of the information provided by this
investigation due to its restricted sample and
methodological limitations. Nevertheless a feature
worth noting is the fact that all speakers were
submitted to nasolaryngostroboscopic examination
which was not a common procedure in similar
published studies (8,9). This study also attempted
to fill some of the gaps in the smoking research
using an instrumental measure to identify stress
level (21).
Further research documenting objective changes
in F0 related to smoking involving a larger sample of
speakers will offer valuable scientific and clinical
information.

Acknowledgements
This research was supported by Calouste Gulben-
kian Foundation funding to the first author.
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