Acute, Repeated Exposure to Mobile Phone Noise and Audiometric Status of Young Adult Users in a University Community

1 Department of Environmental Health Sciences, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria 2 Department of Environmental and Occupational Health, School of Public Health, University of Medicine & Dentistry of New Jersey (UMDNJ), Piscataway, NJ 08854, USA 3 New Jersey Safe Schools Program, Center for School and Community-Based Research and Education, School of Public Health, UMDNJ, New Brunswick, NJ 08903-2688, USA 4 Environmental and Occupational Health Sciences Institute, Robert Wood Johnson Medical School, UMDNJ and Rutgers University, Piscataway, NJ 08854, USA 5 Department of Ear, Nose and Throat, University College Hospital, Ibadan, Nigeria


Introduction
In general, less developed countries are establishing mobile (cellular) phone technology in preference to the traditional, and relatively more expensive, fixed line systems.Therefore, if there are any adverse health risks-potential biological effects-due to acute, repeated (or chronic) personal exposure to radiofrequency radiation from the use of mobile phones, then it will be a global concern; small impacts could have important public health consequences.This may be particularly true among younger adults using mobile phones for calls, music, e-mail, and so forth.
According to WHO [1] and Nelson et al. [2], global prevalence of disabling hearing loss in adults was 16%, which may vary from 7% to 21% in various subregions of the world, and was attributable mainly due to occupational noise.However, with approximately four billion users of mobile phones worldwide [3], and with a significant proportion incorporating media playing capability and speakers, mobile phones are among the most popular portable media players (PMP) on the market and present an emerging health concern in both occupational and nonoccupational settings.Ear pieces, as mobile phone accessories, and most especially the ear bud style of ear phones [4], are able to deposit sounds within the range of maximum levels around 80-115 dBA (Aweighted decibels) directly into the ear canal.The insertion depth of the ear bud of the ear phone into the ear canal, the maximum output provided by the device, and the type of music are factors affecting the amount of sound deposited in the ear canal [5].Katz et al. [6] reported stereo earphones could deliver acoustic sound levels up to 120 dBA.
Rice et al. [7] examined over 60 users of personal cassette players (PCP) and reported the range of measured sound pressure levels was between 60 and 108 dBA.Another study by Wong et al. [8] reported the equivalent measured music noise levels ranged 56-116 dBA among 394 PMP users.In the same Wong et al. study [8], the prevalence of regular use of PCP in Hong Kong-for at least three days a week for six months-among 487 individuals age 18-24 years was 81%.Ising et al. [9] reported among 681 pupils who used minicassette players (MCS), a type of PCP, equivalent measured music noise levels were 60-110 dBA.Smith et al. [10] reported in their study of social noise among 18-25 year olds in the UK that the preferred average sound level (volume) for listening to PMP was 74 dBA.Catalano and Levin [11] reported in their study of 154 college students in New York City a prevalence of portable radios (PR) with headphones of 31.4%, with mean duration use for females 8 ± 10 hours/week and among males 14 ± 10 hours/week.Overall, PR, PCP, and PMP with head phones may be capable of causing permanent hearing loss in a large population of users [11,12], and now mobile phones with ear pieces are replacing them.
In a study [13] to determine the hearing threshold of mobile phone users who had used a mobile phone for a minimum of one year, a significant difference in the mean threshold levels of users (0.12±5.9 dB) and nonusers (−3.0± 4.7 dB) was reported (P < 0.05), with detectable responses found at each frequency (500 to 8000 Hz) except at 250 Hz.Duration of mobile phone use was also related to these threshold changes (P < 0.05) [13].
According to Welleschik [14], 85 dBA is regarded as the critical intensity; exposures below this have lower rates of hearing impairment.International standards recommend the sound pressure level equivalent for an 8-hour (Leq, 8 h) working day weighted average of 85 dBA as the exposure limit for occupational noise [15,16].However, this limit may not guarantee the safety of the worker's auditory system.The regulations of the European Commission (EC) on noise at work (Directive 2003/10/EC) [16] thus recommended three action levels for occupational settings depending on equivalent noise levels for an 8-hour working day.Equivalent values (see Table 1) result when values are converted using a time-intensity tradeoff of a 3 dB increase for cutting the time in half.For example, listening to music on a PMP or mobile phone at 95 dBA for 15 minutes a day would equate to the first action level, assuming repeated exposure.
Constant exposure to noise from mobile phone sources is suspected to adversely affect hearing and potentially lead to other adverse outcomes like cancers [17,18], but data are limited, particularly in rapidly urbanizing and growing areas of less developed countries.To date, exposure science research on mobile phones focused on radiofrequency (RF) radiation measures [19,20], mobile phone attributes potentially affecting exposure [21], and potential recall bias in surveys in retrospective epidemiologic study designs [22].
Therefore, this pilot study's quantitative measures assessed noise levels from mobile phones and user audiometric status at University College Hospital, Ibadan, Nigeria.

Materials and Methods
This study went through proper required institutional review board procedures at the College of Medicine, University of Ibadan, Nigeria, prior to its initiation, and informed consent was obtained from study participants.Approval for the study was also obtained from the University College Hospital Ethics Committee (UI/EC/08/0134).

Study Design.
A cross-sectional design was adopted for this pilot study.The goal was to achieve a total sample size of at least 100 people; 103 participants consented to participate in this pilot study using a stratified random-sampling technique in the University of Ibadan community.The exclusion criteria implemented after originally identifying these potential participants included history of chronic ear disease; recent upper respiratory infection; exposure to loud noise from clearly identified sources at work and/or at home beyond mobile phones and use of PMPs, PCPs, and PRs; a history of any chronic medication within the last three months.Thus, 58 staff and 45 students who owned mobile phones and used them for at least one year were included.

Preliminary Survey.
Participants completed a questionnaire which elicited information on demographic characteristics (e.g., birth year, gender) and sought to identify the ear (right or left) typically used for making and receiving calls.Mobile phone types (e.g., brand, size, accessory, and headphone compatibility) and other user practices were also assessed using an observation checklist.

Noise Measurements.
In this pilot study, acute, repeated exposure referred to use of mobile phones, that is, personal contact with RF radiation.Noise (sound levels) of mobile phones during inactive and active modes was determined using a calibrated AMEC sound level meter.The calibration tool was NIST certified at 94 dBA.This sound level meter could measure noise, in dBA (used) or C-weighted decibels, at a fast or slow response time and between 35 and 130 dBA in three expected noise ranges; the fast response time and mid-high ranges of expected noise (50-100 and 85-130) were used.Noise levels were compared to aforementioned EC and World Health Organization (WHO) occupational exposure limit [1,15,16] as no other personal exposure standards yet exist.

Audiometric Assessment.
Pure tone audiometry (PTA) was performed bilaterally on study participants at frequencies 500, 1000, 2000, 4000, and 8000 Hz.The dominant ear PTA results were compared with the nondominant ear PTA

Demographic Information of Study Participants.
The study population comprised students (43.7%, n = 45) and staff (56.3%, n = 58), of which overall 69% were single and 31% were married.The mean age of students was 23.8 ± 2.9 years compared to staff 35.5 ± 7.6 years (P < 0.05).

Mobile Phone
Profile.Nokia, Samsung, Sagem, and Sony Ericsson were the major phone types used by both students and staff (Table 2).The mean duration of mobile phone use for students was 2.9 ± 1.7 years compared to staff 3.4 ± 1.9 years (P < 0.05).

Noise (Sound Levels
) from Mobile Phone.Mean noise produced by mobile phones of students was 93.1 ± 16.1 dBA compared to staff 88.6 ± 11.0 dBA (Table 3).Mean noise produced by mobile phones of both staff and students exceeded the WHO limit for occupational exposure (85 dBA) even though they were of short duration; in this study, dose appears to be driven by intensity (sound level) and frequency of phone use, not duration of exposure.There was a borderline statistically significant difference (P = 0.05) in the ear used in making or receiving a call among students and staff (Table 4).Table 4 shows 38/45 (84%) students and 36/58 (62%) staff in this pilot study that reported a preference for using their right ear when receiving calls.There was also  a significant difference (P < 0.01) in the use of mobile phone accessories among students and staff (Table 5).Table 5 shows half of students reported a preference for using the speakers, and another 22% (10/45) ear pieces, whereas most staff (42/58, 72%) reported using no accessory with phones.

Hearing Threshold.
A total of 34 students and 40 staff had hearing values considered as normal, based on PTA results, while 12 students and 17 staff had evidence of impaired hearing (Table 6).There was, however, no statistical difference in the hearing of students and staff (P > 0.05) (Table 6).Note: percentages were summed down columns, that is, by occupational status, and then overall by hearing status.Comparison between occupational status and hearing status showed no statistically significance under Chisquare test.

Audiometric Status of Study
Participants.Some evidence of hearing impairment of 27.0% was noticed on the right ear, while 38.5% was noticed on the left ear, as compared to no hearing impairment for those who had no reported preference (Table 7).A comparison of the hearing status of respondents by gender, across occupational status, suggested greater hearing impairment among females as compared to males (Table 8)-6/40 (15%) males versus 24/63 (38%) females showed some evidence of hearing impairment via audiometry.This difference was statistically significant (P < 0.01).A comparison of the mean hearing levels on the left ear of students and staff across frequencies used in PTA (Figure 1) revealed declines in high frequencies notes heard by staff, which suggested noise-induced hearing loss (NIHL) at frequencies above 4000 Hz.We also observed the mean pure tone heard by students at 500 Hz was 30 dBA, which indicated a 5 dB loss at 500 Hz relative to the standard (Figure 1).On the right ear, mean hearing levels heard by both student and staff were below the hearing threshold for frequencies used in PTA in this study (Figure 2).

Discussion
Mobile phones play an important role in providing the fastest means of communication amongst populations globally, yet its usage is also associated with potential public health hazards.Our study to the best of our knowledge is one of the first on health-related hazards associated with acute, repeated exposure to noise from mobile phone and music player use, and the first in a less developed country.In this study, phone types, phone-related noise levels, and audiometric status of phone users were assessed.Though this pilot study had known limitations like a cross-sectional design, which precluded more rigorous assessment of chronic exposure and past occupational and/or residential exposure, and a relatively small sample size due to limited resources available, selection (exclusion) criteria attempted to minimize bias.The data are novel and will inform future research-a recent US Government Accountability Office report on mobile  phone RF radiation exposure and testing requirements concluded data remain sparse, especially in consideration of when people transport and use mobile phones against bodies [23].
A high prevalence of Nokia branded mobile phones was reported in our study.Similar findings have been reported in studies by Shayani-Nasab et al. [13] and Usikalu and Akinyemi [24].The mean sound level (noise) produced by mobile phones of participating students was higher than that produced by participating staff mobile phones; however, this difference was not significant.Both the mean sound levels of the mobile phones of students and staff were greater than the critical intensity of 85 dB (A) reported by Welleschik [14].This is also in line with the conclusions made by Fligor and Cox [4]; that is, PMPs and mobile phones inclusive along with ear phones are able to deposit sounds within the maximum levels around 80-115 dBA directly into the ear canal.In this study, the majority of students utilized an accessory for their mobile phone while only a minority of the staff population utilized any mobile phone accessory.The results of this pilot study can inform future educational interventions, especially with adolescent and young adult students, regarding user mobile phone settings and proper use of the various optional accessories available.It should be noted that a recent study by the US National Institute for Occupational Safety and Health [25] reported the educational services industry ranked fourth among industries with highest percentages of adult workers with measured hearing loss in employer tests conducted 2000-2008.Thus, university settings are appropriate for interventions.
A preference sound level of 74 dBA among 18-25 years old users of PMPs was reported by Smith et al. [10], and sound levels of PCPs [7], PMPs [8], and MCS [9] were reported to be in the range of 50-120 dBA.Noise (sound levels) produced by mobile phones of young adult students and staff in this study was closer to the upper limit of this previously reported range.Furthermore, the majority of participating students and staff had preferences for the right ear in making and receiving calls; similar findings were observed in findings of Shayani-Nasab et al. [13] and Velayutham et al. [26].These results can again inform future educational interventions; for example, users should alternate ears used and reduce volume.
There was a significant difference in mean duration of mobile phone use among students and staff.Pure tone audiometry revealed there was, however, no statistically significant difference in evidence of hearing impairment over the range of frequencies 500, 1000, 2000, 4000, and 8000 Hz among young adult students and staff.A statistically significant difference was noticed when hearing status was stratified by gender.Longitudinal studies on prevalence of hearing impairment and possible reasons for observed disparities by and across age are needed.It should also be noted that a recent prospective study of noise exposure and hearing damage among 316 construction workers with two or more annual examinations over 10 years further confirmed the standard hearing threshold level evaluation via pure tone audiometry was sufficient [27].
Mean hearing values of young adult students and staff compared over the range of frequencies 500-8000 Hz suggested evidence of a decline in staff hearing above 4000 Hz, suggesting possible NIHL, whereas a 5 dB hearing loss was noticed for students at 500 Hz but not at higher frequencies.In this study, mean reported mobile phone use duration by staff was 3.4 ± 1.9 years and by students was 2.9 ± 1.7 years (P < 0.05).An increase in reported mobile phone use duration was also previously observed to be associated with NIHL or threshold shift [13,26].

Conclusions
Our pilot study suggested noise levels in A-weighted decibels from mobile phones of different manufacturers exceeded the critical levels for equivalent noise levels for an 8hour working day.Evidence of hearing impairment was higher among those reporting longer duration mobile phone use, and among females.A shift in emphasis of future research from cancer promoting effects of mobile phones to noncancer outcomes with longitudinal study designs, including noise-induced hearing loss, in both industrialized and less developed countries, is warranted.Our results can also inform future educational interventions, especially with adolescent and young adult students in university settings, regarding user mobile phone settings, for example, reduce

Figure 1 :Figure 2 :
Figure 1: Mean hearing level of the left ear of respondents at various frequencies.
results.Audiologic examination was performed by experienced audiologist in University College Hospital, Ibadan, Nigeria, after screening using an otoscopic examination.The audiologist was blinded and thus did not know which ear was stated by the participant as being preferred or dominant.2.5.Data Analysis.Data analysis was performed using SPSS version 15.0 after data entry and management in Microsoft Excel.Independent t-tests and Chi-square tests were used for the analysis of statistical significance at P < 0.05.

Table 2 :
Major manufacturers of mobile phones reported as used by respondents.
Note: some of the 58 students and the 45 staff reported more than one phone owned and used.

Table 3 :
Mean noise levels (in A-weighted decibels, dBA) of respondent mobile phones.

Table 4 :
Ear reported used in making or receiving a call by occupational status.

Table 5 :
Mobile phone accessories reported used by occupational status.
Note: as each accessory was assessed separately with the questionnaire, percentages were summed down columns, that is, by accessory, and then overall by occupational status.Comparison between mobile phone accessories used and occupational status showed a statistically significant difference at P < 0.01 under Chi-square test.

Table 6 :
Hearing status per pure tone audiometry by occupational status.

Table 7 :
Hearing status of respondents by reported ear of preferred use.: percentages were summed down columns, that is, by preferred ear used, and then overall by hearing status.Comparison between the dominant ear and the nondominant ear showed no statistically significance under Chi-square test (i.e., P > 0.05). Note

Table 8 :
Hearing status of respondents across occupational status and age by gender.