Gaming Could be a Contributing Factor to Hearing Loss and Tinnitus

Dangerously misleading “safe” listening information is shared in a recent article in the British Medical Journal that found gaming could lead to hearing loss and tinnitus. Risks included gaming at loud volumes with headphones or earbuds as well as risk from noisy exposures at gaming arcades or competitions.

This isn’t surprising news. We’ve known since before the 1970s that loud exposures over time can cause permanent hearing loss and tinnitus. Turn down the volume. Use well-fitting or properly inserted hearing protection in noisy loud environments. There are even earplug and earmuff options that allow safe wired or wireless personal listening. 

The major problem with this study is the dangerously misleading content suggesting that “occupational equivalent” or weekly average (dB Lex,40-hour) noise exposures are “safe” for public health, including children and teens. It is wrong to use this type of time weighted average in public health. It leads to these incorrect conclusions that harmfully loud noise exposures are “safe” at shorter listening times. The authors and peer reviewers failed to provide a factual science-based noise risk assessment.

The media is now passing on this dangerous information about “safe” listening to a general public with little understanding of noise risk. Using statements from the gaming study, an ign.com article shares that based on occupational equivalent exposure guidelines, “adults were advised to listen to 83 dB sounds for no more than 20 hours per week, but for children that duration would drop to 6.5 hours.” In making these statements about blatantly unsafe exposures, the authors fail to mention:

• To prevent hearing loss, daily average noise limits for the public are recommended at/below 70 dB, depending on age. (EPA, 1974, WHO, 1999, 2018)
• 83 dB exposures are linked to high risk of permanent progressive neurosensory hearing health damage, including potential risk of noise-induced auditory brain damage in children and teens.

Public Health Daily Average Noise Exposures

Around the 1960s and 1970s, risk of hearing loss was first established for adults exposed to occupational noise. Hearing loss was measured using a standard audiogram or hearing test, and reflects noise damage to the inner ears or cochleas.

Adult hearing loss risk was based on daily average 8-hour equivalent or time weighted average exposures (dB Lex,8-hour) over a 40 hour work week and 40 year working career. In 1998, the National Institute of Occupational Safety and Health (USA) recalculated earlier noise risk estimates for unprotected exposed workers finding:

• 1% risk of hearing loss at 80 dB.
• 8% risk of hearing loss at 85 dB.
• 25% risk of hearing loss at 90 dB.   

Workers exposed above daily occupational limits are required to wear hearing protection during harmful noise exposures, have yearly hearing screening, etc. Permissible limits vary widely depending on the jurisdiction or country where the work is happening.

Scientists knew that permissible occupational exposure limits were not protective enough to prevent noise-induced hearing loss over a person’s lifetime. Experts recommended lower daily average noise limits for non-occupational noise, including environmental, community, and entertainment or leisure noise. Noise risk was based on the measured daily average noise levels (dB Leq,24-hour).

Table: Public Health Recommended Daily Average Noise Limit

Daily Noise Limit to Prevent Hearing Loss in Exposed Adults* (dB LAeq,24-hour)	Public Health Source
70 dB	1974 Environmental Protection Agency (USA). Information on levels of environmental noise requisite to protect public health and safety with an adequate margin of safety.
70 dB	1999 World Health Organization. Guidelines for community noise.
70 dB	2018 World Health Organization. Environmental noise guidelines.

In 1974, the Environmental Protection Agency (USA) called 70 dB the “Effective Quiet” level, where exposures above 70 dB were considered unsafe no matter how short (Pienkowski, Figure 1, 2021). Above 70 dB daily average exposure, hearing protection is recommended if the volume can’t be turned down.

This is because when harmful sound sources are intense enough to damage hearing health, there is no such thing as a “safe” noise dose. Our ears and brains don’t average sound input over hours. The total incoming sound energy (dB Leq,24-hour) must travel through the hearing system in real time. Compared to 70 dB, about 2 hours unprotected exposure at 81 dB has a similar hearing loss risk as 8 hours at 75 dB. 

Table: 70 dB Equivalent Noise-Hearing Loss Risk

Daily Average Noise Exposure	Equivalent Hearing Loss Risk to 70 dB (Leq,24-hour)
75 dB	8 hours
78 dB	4 hours
81 dB	2 hours
84 dB	1 hour
87 dB	30 minutes
90 dB	15 minutes
93 dB	7.5 minutes
96 dB	<4 minutes
99 dB	<2 minutes

Over time, science has proven loud noise damage to hearing health extends far beyond the inner ears. Permanent progressive noise-induced damage includes hearing nerve degeneration and impaired sound processing connections in the brain, which happen long before damage develops in the inner ears or cochleas. 

Noise damage can cause hearing loss and hidden hearing loss, including tinnitus, hyperacusis, impaired speech understanding, and distorted pitch perception (diplacusis). Hidden hearing loss, impaired otoacoustic emissions from the cochleas, and extended high frequency hearing loss (>8000 Hertz) can develop while hearing thresholds still test within the normal range on a standard audiogram. 

There are many reasons children and teens are considered noise sensitive, needing better protection than mature adults. This includes the lifelong negative consequences of early-onset hearing loss, from impaired interpersonal relationships, problems learning at school, and mental health issues including anxiety and depression. 

We’ve also learned that children and teens are at high risk of permanent brain damage from noise exposures during peripheral and central auditory system development into the late teens to early 20s. In Noise and the Brain, renowned Canadian researcher Jos. J. Eggermont identifies potential risk from 65+ dB amplified noise exposures during hearing system developmental periods in children and teens. Eggermont also identifies the auditory injury threshold at 75 – 78 dB regardless of listening time. This was first documented decades ago by Kryter, famed American noise scientist. 

Table: Amplified Audio Risk to Hearing Health

Estimated Intensity	Perceived Loudness	Noise-Induced Hearing Health Risks Include*
100 dB+	Extremely Loud	Immediate injuries can include burst eardrum(s). Temporary hearing changes linked to permanent hearing nerve degeneration. Neurosensory hearing loss. Hidden hearing loss, e.g. tinnitus, hyperacusis, pitch distortion or diplacusis.
80 dB+	Very Loud	Temporary hearing changes linked to permanent hearing nerve degeneration. Neurosensory hearing loss. Hidden hearing loss, e.g. tinnitus, hyperacusis, pitch distortion or diplacusis.
75-78 dB Auditory injury threshold regardless of listening time.
70 dB+	Loud	Hidden hearing loss, e.g. tinnitus, hyperacusis, pitch distortion or diplacusis. Low risk of hearing loss.
<70 dB	Quiet to Moderately Loud	Safer for adult hearing health.
<65 dB**	Quiet to Moderately Loud	Safer for noise sensitive people, e.g. children to teens, anyone with pre-existing sensorineural hearing loss, tinnitus, and/or hyperacusis.

Occupational Equivalent Noise Exposures

Personal listening system guidelines are the source of occupational equivalent exposures. In 2018, the International Telecommunications Union recommended weekly average noise exposures in so called “safe” guidelines for personal audio system manufacturers. These guidelines included recommendations for dosimeter systems to track user exposure and give warnings or alerts if exposures exceed “safe” or “permissible” exposures. The weekly average calculation is so weak that users likely wouldn’t get unsafe listening alerts even at exposures linked to permanent hearing health damage.

In 2019, the World Health Organization compromised with the International Telecommunication Union to jointly recommend occupational equivalent exposures in their “safe” guidelines on personal listening devices. Manufacturer warning system alert options include 80 dB+ weekly average exposures (Lex,40-hour) intended for adult users and 75 dB+ alerts intended for noise sensitive populations like children, teens, and people with pre-existing sensorineural hearing loss. The math is complex, but dangerous when scientists interpret it to mean 83 dB exposures are considered “safe” for anyone.

The World Health Organization used to recommend a 60-60 rule for personal listening: no more than 1 hour a day at 60% volume (about 80 dB). Under “how to protect my hearing”, the World Health Organization (2022) stated, “If you are using an app to monitor your sound level, it is best to stay below 80 dB average.” This isn’t completely “safe” for hearing health. But it is much safer than the occupational equivalent guidelines now being shared.

Unfortunately, these weak occupational equivalent guidelines with a poor margin of safety are now being used generally for leisure noise, outside of personal audio systems. The World Health Organization has never justified why they decided to ignore the long established 70 dB daily average noise limit to prevent hearing loss when they teamed up with the International Telecommunications Union. Others have recommended the continued use of daily average exposure limits to best protect public hearing health (Neitzel & Fligor, 2019; Mayes & Fink, 2021).

Authors, peer reviewers, and journalists can state that 83 dB is a “safe” exposure for children, teens, and adults. This doesn’t make it factual. These statements should certainly come with a warning or disclaimer that daily average exposures above 70 dB are linked to permanent progressive hearing health damage. 

If people want to listen loud, that’s their right. But we are failing future generations if we don’t allow an adequate margin of safety to protect their hearing health. We are certainly failing future generations when we allow special interest groups to weaken the previously established 70 dB daily average public health noise limit.

References

• Eggermont, J.J. (2014). Noise and the brain: Experience dependent developmental and adult plasticity. Cambridge, Massachusetts: Academic Press.
• Environmental Protection Agency. (1974). Information on levels of environmental noise requisite to protect public health and safety with an adequate margin of safety. United States Environmental Protection Agency; EPA/ONAC 550/9-74-004.
• Feder, K., Marro, L., McNamee, J. & Michaud, D. (2019). Prevalence of loud leisure noise activities among a representative sample of Canadians aged 6-79 years. JASA, 146(5): 3934-3946, https://doi.org/10.1121/1.5132949
• Mayes, J. & Fink, D. (2021). Unsafe at any sound: Hearing loss and tinnitus in personal audio system users. Proceedings of Meetings on Acoustics. 43, 040003. https://doi.org/10.1121/2.0001452
• National Institute for Occupational Safety and Health. (1998). Criteria for a Recommended Standard: Occupational Noise Exposure. Cincinnati, OH. https://www.cdc.gov/niosh/docs/98-126/pdfs/98-126.pdf
• Neitzel, R.L. & Fligor, B.J. (2019). Risk of noise-induced hearing loss due to recreational sound: Review and recommendations. JASA, 146(5): 3911-3921. https://doi.org/10.1121/1.5132287
• Pienkowski , M. (2017). On the etiology of listening difficulties in noise despite clinically normal audiograms. Ear & Hearing, 38(2):135-148 https://dx.doi.org/10.1097/AUD.0000000000000388
• Pienkowski, M. (2021). Loud music and leisure noise is a common cause of chronic hearing loss, tinnitus, and hyperacusis. International Journal of Environmental Research and Public Health, 18(8): 4236. https://pubmed.ncbi.nlm.nih.gov/33923580/
• World Health Organization (1999). Guidelines for community noise.
• World Health Organization. (2018). Environmental noise guidelines for the European region. WHO Regional Office for Europe. https://www.euro.who.int/en/publications/abstract/environmental-noise-guidelines-for-the-european-region-2018
• World Health Organization. (2020). World Report on Hearing. License CC-By-NC-SA 2.0 IGO. https://www.who.int/publications/i/item/world-report-on-hearing
• World Health Organization (2022). Deafness and hearing loss: safe listening.
• ITU (2018). Recommendation H.870: Guidelines for safe listening devices/systems. International Telecommunication Union. https://www.itu.int/rec/T-REC-H.870-201808-I/en
• Safe listening devices and systems: a WHO-ITU standard. (2019). Geneva: World Health Organization and International Telecommunication Union. Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/safe-listening-devices-and-systems-a-who-itu-standard