Although tinnitus is a very common symptom, risk factors related to behavior and habits have not been sufficiently investigated. As no investigation on this problem has been performed in Serbia, the aim of our study was to establish the prevalence of tinnitus among Serbian adolescents and to investigate the relationship between their behavior and habits and tinnitus. This investigation was designed as a cross-sectional interview study among secondary school students in Belgrade, Serbia (277 boys and 494 girls). An anonymous questionnaire was self-administered at classes. The investigated variables were: The presence of tinnitus, sources of noise, night outs at noisy places, use of personal music players, smoking, second hand smoke (SHS), substance abuse, coffee and alcohol consumption. Spearman's rank-order correlations and multiple logistic regressions were performed with variables related to behavior and habits as independent ones and tinnitus as a dichotomized dependent variable. Tinnitus was reported by 99 students (12.8%), more frequently among girls compared with boys (P = 0.009). Multivariate logistic regression analysis in boys revealed a significant independent effect of a regular drug abuse on the onset of tinnitus. The chances of tinnitus were 13 times higher among drug addicts compared with non-drug users (odds ratio [OR] and 95% confidence interval [CI] for tinnitus = 13.072; 1.335-127.946). In girls, the significant independent effect on tinnitus was found for daily duration of exposure to SHS (OR and 95% CI for tinnitus = 1.328; 1.073-1.644 /per 2 hours of exposure/).
Keywords: Adolescent, drug abuse, noise, second hand smoke, smoking, tinnitus
|How to cite this article:|
Marmut Z, Belojevic G, Backovic D, Zivojinovic JI, Tomanic M, Hadzic E. Tinnitus among Serbian secondary school students in relation to their behavior and habits. Noise Health 2014;16:73-8
|How to cite this URL:|
Marmut Z, Belojevic G, Backovic D, Zivojinovic JI, Tomanic M, Hadzic E. Tinnitus among Serbian secondary school students in relation to their behavior and habits. Noise Health [serial online] 2014 [cited 2020 Nov 25];16:73-8. Available from: https://www.noiseandhealth.org/text.asp?2014/16/69/73/132080
| Introduction|| |
Tinnitus is the perception of sound or noise in the absence of an external or internal sound source. It is a common complaint, which is mainly resistant to treatment. , About 10-15% of the adult population is affected by tinnitus.  There are about 50 million US adults reported having any tinnitus and 16 million US adults reported having frequent tinnitus in the previous year.  In a large cross-sectional study in the United States tinnitus was reported by 7.5% of 3520 individuals aged 12-19 years.  About 1-2% of the general population experience significant impairments in their quality-of-life due to tinnitus.  The National Study of Hearing in England showed that the prevalence of tinnitus among adults was 10.1% and in 0.5% of respondents tinnitus severely affected the ability to lead a normal life.  There are different perceptions and many degrees of distress among people who experience tinnitus. For someone, it can be just a simple awareness, but it can also be so loud that a person has difficulty in hearing. Severe tinnitus can provoke heterogeneity of psychological symptoms like tension, frustration, impaired concentration, depression and disrupted sleep. , The studies show that the odds ratio of tinnitus is raised by about 3%, with each year of age and that there is a higher risk of tinnitus for men compared with women. 
Etiology of tinnitus is diverse and it includes: hearing loss caused by: Infection, loud noise, cerumen impaction, presbycusis, mercury or lead poisoning, Ménière's disease, lyme disease, ototoxic drugs (aspirin, non-steroidal anti-inflammatory drugs, antibiotics, diuretics, antidepressants, biostatics); depression and anxiety, multiple sclerosis, head injury, iron deficiency anemia, hypercholesteremia, thyroid disease, vitamin B12 deficiency, migraine, benzodiazepine withdrawal, nasal congestion, hypertension and head or neck tumors. 
Although tinnitus is a very common symptom, just a few risk factors related to behavior and habits have been proved.
The prevalence of tinnitus may increase as a consequence of exposure to environmental factors, for example exposure to loud noise during leisure time activities and especially in young people. Even 17% of teens may have hearing problems probably due to non-professional noise exposure; it is so called socioacusis.  It has been estimated that 85% of tinnitus cases are accompanied by hearing loss and that occupational and leisure noise are the major factors causing cochlear damage.  The most of young adults are mainly exposed to excessively loud music from personal music players (PMP) and during attendance at music concerts and nightclubs. 
Smoking and second hand smoke (SHS) are of great public health concern and these factors have also been related to tinnitus in two recent investigations. In a study on adult smokers from both genders between 20 and 31 years of age, there were more cases of cochlear dysfunction and tinnitus than in non-smokers.  In a recent US study on subjects aged 12-19 years, a multivariable-adjusted analysis revealed that tinnitus was associated with passive smoking and female gender. 
The association between use of various illicit drugs and hearing impairment or damage was described in several clinical and epidemiological studies. ,,,, Sudden sensorineural hearing loss, presumably of cochlear origin, may be a rare complication of incident drug abuse, , whereas chronic tinnitus is connected with the duration of inhalant and hallucinogen drug dependence.  Alcohol consumption among adolescents may also be associated with tinnitus. 
In general, there is a lack of studies on behavior and habits and tinnitus. Of special public health concern are recently published two studies, mentioning the relation of smoking and SHS to tinnitus. , Investigations on this problem from different world regions are needed to re-evaluate the obtained results from previous studies. The aim of this first study of a kind in Serbia is to establish the prevalence of tinnitus among Serbian adolescents and the relationship between their behavior and habits and tinnitus.
| Methods|| |
This cross-sectional study was conducted in two secondary schools in Belgrade: 13 th Gymnasium and Chemical School, during 2005. The sample encountered students from all four classes. The sample consisted of a total of 771 students, 277 boys (35.9%) and 494 girls (64.1%). The response rate was 92% (771 out of 835 distributed questionnaires). An average age of participants was 17.6 ± 1.1 years, ranging from 14 to 20 years.
A questionnaire with closed questions was used as an investigation instrument. The investigated variables were: Gender, age, major sources of noise in the environment (traffic, construction works, industrial facilities, neighborhood, elevator and installations in the house), five graded verbal noise annoyance scale ("Thinking about the last 12 months, how much does noise bother you, annoys you or disturbs you at home; not at all = 0; a little = 1; moderately = 2; very much = 3; extremely = 4), time of the day when most disturbed by noise (day; night; day and night), night outs at noisy places (never or less than once a month = 0; 1-3 times a month = 1; 1-3 times a week = 2; 4-6 times a week = 3; every day = 4), average duration of stay at noisy places (hours), use of PMP (never or less than once a month = 0; 1-3 times a month = 1; 1-3 times a week = 2; 4-6 times a week = 3; every day = 4) (average daily use in hours) ("How do you usually adjust volume when using PMP? - "low"; "medium"; "high"), the presence of tinnitus ("Do you feel occasional or permanent buzzing or ringing in your ears?"), smoking (smoker; ex-smoker, no) (for smokers - duration/years/ - 1-5; 6-10; 11-15; 16-20; more than 20; number of cigarettes daily - 1-5; 6-10; 11-15; 16-20; more than 20, exposure to SHS ("Are there any smokers at your home", "What is the average daily time you spend indoors with environmental tobacco smoke - never = 0; 1-2 h = 1; 2-4 h = 2; more than 4 h = 3; coffee consumption (never = 0; rarely = 1; 1-4 cups daily = 2; more than 4 cups daily = 3; and alcohol consumption (never = 1; occasionally without getting drunk = 2; every day without getting drunk = 3; occasionally getting drunk = 4; every day getting drunk = 5; and substance abuse ("Have you ever tried any illicit drug", "If yes, which one?" "If yes do you still use it ?").
An anonymous questionnaire was self-administered at classes on 1 day.
In descriptive statistics, we used percentage calculation. Student's t-test was used to compare means of variables in independent samples (gender) and Chi-square test was used to test differences between categorical variables in relation to gender. Spearman's rank-order correlations and multiple logistic regressions were performed with variables related to behavior and habits as independent ones and tinnitus as a dichotomized dependent variable. We hypothesized a significant moderating role of gender in behavior-habits-tinnitus relation.
| Results|| |
Tinnitus was reported by 99 students (12.8%) and was more frequently present among girls compared with boys (75/15.2% and 24/8.7%, respectively; Pearson Chi-square = 6.84, P = 0.009).
Behavioral and habits factors of students in relation to gender are presented in [Table 1]. Active smoking was reported by every ninth student and was similarly distributed among boys and girls. However, boys smokers smoked longer compared to girls (mean ± standard deviation, 1.3 ± 1.0 and 1.0 ± 0.3 years, respectively; P = 0.029) with a higher daily number of smoked cigarettes (3.5 ± 1.3 and 2.6 ± 1.3, respectively; P = 0.003). Exposure to SHS was reported by every second student and was more frequently present among girls, compared to boys. Drinking more than four cups of coffee was reported by about 2% of students and was more frequent among boys, in comparison to girls. Occasional and regular drinking with getting drunk was reported by 23% students and was more frequent among boys, compared to girls.
|Table 1: Demographic characteristics and behavioral patterns of students|
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Experience with drugs was reported by every 12 th student and was more present among boys, compared with girls. Regular drug abuse was reported by 2% of students and was similarly distributed among boys and girls. The drugs regularly used were marijuana (65%), heroin or cocaine (20%) and "ecstasy" (15%). There were more boys with four and more night outs per week, in comparison with girls. The average time spent in night outs was 4.1 h and was similar in boys and girls. About 89% of students used PMP and it was more frequent among girls. There were 65% of students who listened to PMP every day for 2.4 h on average and about 50% of them regularly chose the maximum volume and these habits were similar in boys and girls.
Using bivariate Spearman's correlation analysis in boys we found a positive significant relation of tinnitus with smoking, exposure to SHS and daily duration of exposure to SHS, alcohol and coffee consumption and regular drug abuse. In girls, a negative significant relation of tinnitus was found with age while positive significant relation was found with daily time spent indoors with environmental tobacco smoke [Table 2] and [Table 3].
|Table 2: SC for significant correlations between tinnitus and behavioral factors in Belgrade boys aged 15-19 years|
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|Table 3: SC for significant correlations between tinnitus and age and exposure to SHS in Belgrade girls aged 15-19 years|
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Multivariate logistic regression analysis in boys revealed a significant independent effect of a regular drug abuse on the onset of tinnitus [Table 4]. The chances of tinnitus were about 13 times higher among drug addicts in comparison with non-drug users. In girls, the significant independent effect on tinnitus was found for daily duration of exposure to SHS [Table 5].
|Table 4: Multiple logistic regression with tinnitus as a dependent variable and some behavioral and habits variables as independent factors among male secondary school students (N = 277)|
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|Table 5: Multiple logistic regression with tinnitus as a dependent variable and some behavioral and habit variables as independent factors among female secondary school students (N = 494)|
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| Discussion|| |
We found tinnitus in 13% of adolescents in Belgrade and more frequently present among girls compared with boys. We show that the exposure to SHS and daily duration of it, smoking, alcohol and coffee consumption and regular drug abuse are significant influencing factors on tinnitus. After controlling for other risk factors, drug addiction and daily duration of exposure to SHS remain significant independent influencing factors on tinnitus in boys and girls, respectively.
The prevalence of tinnitus in our study is similar to that in primary school and junior high school students in central Ankara, Turkey (15.1%)  and to that in 10-year-old children in Jiangsu Province, China (14.5%).  However, the prevalence of tinnitus in our study is higher than in their Swedish mates (8.7%)  and in female adolescents from New York state (3.28%).  Such a wide range of prevalence of tinnitus all over the world may be influenced by a variety of local social and behavioral patterns related to tinnitus. On the other hand, there are also various definitions of tinnitus in different scientific studies.
Concerning gender differences we show a significantly higher prevalence of tinnitus among girls compared with boys. Similar findings are among Brazilian adolescents after attending noisy places (41% in girls vs. 27% in boys).  It may be hypothesized that auditive system in girls is more sensitive to noise in comparison with boys. Furthermore, psychosomatic complaints related to tinnitus seem to be more frequent among female adolescents compared with boys. ,,
Behavioral factors seem to be more important for tinnitus in young people than in elderly. This assumption is supported by findings of Nondahl et al.  who showed that younger American people report a higher prevalence of behaviorally influenced tinnitus than elderly. The main behavioral factors include PMP, MP3 and/or MP4 and exposure to noise during night-outs.  Similar to our finding of nearly 90% of adolescents with daily use of PMP, 99.7% of girls from New York State report regular use of PMP. However, we did not find a significant relation between PMP use and tinnitus. Contrary to our finding, prevalence of tinnitus in Brazilian young people aged from 15 to 30 years is 3 times higher among PMP users compared to PMP non-users (28% and 8%, respectively).  It may be assumed that the difference in listening volume and daily time of use of PMP may explain this heterogeneity of the results. Exposure to excessive sound may destroy hair cells in the cochlea with a consequent activation of different neurons and auditory parts of the brain, reducing the inhibition from the central nervous system and giving auditory phantom sensation. Tinnitus is closely related to hearing loss as a neurologic response to sensory deprivation and the frequencies which cannot be heard are similar to the subjective frequencies of tinnitus. 
Problem behavior and health risk behavior comprises all activities of adolescents that could harm their psychophysical and social health and development. Health risk and problem behavior usually cluster because they may be the manifestations of similar underlying risk factors.  Cigarette smoking is the most common health risk behavior among adolescents and closely connected with other substance abuses.  In our study, we show no significant difference in smoking habits between boys and girls, but girls are more exposed to SHS. Concerning smoking-tinnitus relation we found it to be significant, but among boys only. This finding may be explained with the longer smoking experience and a higher average number of daily smoked cigarettes in boys compared with girls. In Brazilian young adults aged from 20 to 31 years tinnitus was also more frequently found among smokers, compared with non-smokers, but with no gender differences.  A relative novelty in our study is the finding of significant effect of daily duration of exposure to SHS on tinnitus in girls, as a confirmation of recently published similar results of a study on adolescents from the United States.  The relationship between smoking and SHS and tinnitus may be indirect as both smoking  and SHS  are risk factors for hearing loss. The relation between hearing loss and smoking may also be explained by a direct ototoxic (nicotine effect) and by the effect of carbon monoxide on ischemia in the cochlea through the production of carboxyhemoglobin, vasospasm and increased blood viscosity.  Nicotine may also affect higher neural centers with an efferent inhibitory effect on outer hair cells with neurotransmitter acetylcholine.  Smoking also can result in increased susceptibility to ear infection  of which tinnitus is a common symptom. Another explanation of smoking-tinnitus relation may be that anxiety is more frequent among smokers  increasing the awareness of tinnitus. 
We show a positive relation between tinnitus and alcohol consumption but in boys only. Similarly to our finding tinnitus was more frequently found in Swedish students alcohol-drinkers compared to non-drinkers.  Cross-sectional surveys among 15-16 year old students in 30 European countries by The European School Survey Project on Alcohol and other Drugs documented that an absolute majority have consumed alcohol at least once in their lifetime and about two-thirds of the students have had an alcoholic beverage in the past 30 days.  However, among girls we found a negative borderline significant relation between tinnitus and alcohol drinking (P = 0.10). Congruent with this finding are the results of a study among American women of a decreased risk of tinnitus in the case of drinking alcohol in the year prior to investigation, compared to non-drinkers.  It seems that moderate drinking may have protective effect on auditory system with a decreased risk of developing tinnitus,  while in chronic alcoholism ototoxic effects of alcohol are pronounced.  Moderate alcohol consumption may be beneficial in improving high density lipoprotein cholesterol and microcirculation in cochlea. 
Concerning the relation between drinking coffee and tinnitus we found it to be significant, but in boys only. However, in an observational study in UK a withdrawal of usual caffeinated tea/coffee was not helpful in patients with tinnitus.  Although it is common among ear nose and throat practitioners to advise reduction of coffee consumption to patients with tinnitus, it seems that there is no scientific support for this attitude. On the contrary, coffee may have a protective effect on auditory neuropathy.  That is why we may assume that our finding of positive relation of coffee consumption to tinnitus may be regarded as a statistical coincidence.
Finally, we show a positive relation between tinnitus and regular drug abuse. Drug addiction and especially marijuana use was the single most important independent risk factor for tinnitus in boys. In a large nationally representative sample in the USA, among 35-49 years old people, a positive association between duration of some illicit drugs use and tinnitus was observed.  Illicit drugs may increase the chance for tinnitus for 2.4 times. This effect may be explained by fluctuations in the blood supply of cochlea or by dysregulation of cochlear N-methyl-D-aspartate receptors and aberrant firing of the auditory nerve as a direct ototoxic effect of illicit drugs.  Concerning gender differences in our study, there were more drug users among boys than girls. Explanation could be in different behavioral and coping strategies between female and male adolescents. Girls often express internalizing behavior, with more emotional, depressive or psychosomatic problems, while boys may externalize problems through violence and extreme substance abuse. 
The limitation of our study is that we did not control for other possible causing factors of tinnitus, beside noise exposure, namely: Hearing loss, ear infections, multiple sclerosis, foreign objects in the ear, wax build-up, allergic rhinitis, use of ototoxic medicines such as aminoglycoside antibiotics and withdrawal from benzodiazepines and marijuana. However, non-acoustic causes of tinnitus may rarely be found in adolescents and we consider this error acceptable.
| Acknowledgment|| |
This study has been financially supported by the Serbian Ministry of Science, Project No. 175078/2011.
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Prof. Goran Belojevic
Institute of Hygiene and Medical Ecology, Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade
Source of Support: This study has been financially supported by the Serbian Ministry of Science, Project No. 175078/2011,, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]