Hearing Loss: Fixing Problems at Their Sources

Before I discovered quieter places to study at University of Maryland than the McKeldin

Library, I was constantly forced to relocate myself throughout the library, as other students would seat

themselves by me and subject me to the sickening, thrashing music which they listened to on

headphones. Initially, I thought that playing music on headphones so loudly so that others can hear it

from across a room was a trend, done intentionally so that everyone would hear what music the person

was listening to and think that he or she was “cool.” An incident in the much-abused “Silent Study

Room” at the McKeldin Library, however, made me realize otherwise.

One morning I strode briskly through the McKeldin Library toward the Silent Study Room,

eager to escape the irritating din of the main floor and enter the only quiet place on campus that I knew

of (I have since found quieter places, but I will not disclose their locations due to my self-interest in

keeping them hidden). I set down my bag and pulled out my books, but as I settled into reading, my

attention was drawn to the jarring clash of sound that I quickly identified as the music that a girl sitting

roughly twenty feet away from me was listening to on headphones. We were the only people in the

room, and for fifty minutes her music echoed abrasively as if amplified in a cave. Finally, when I could

no longer tolerate or afford the distraction, I politely asked the girl to turn down her music. She did not

hear me. I addressed her again, this time louder, but she still did not notice me. I tapped her shoulder

and she turned, and I requested that she lower the volume of her headphones, explaining that I could

hear her music from the other side of the room. She apologized profusely: “You can hear that? Oh my

god, I’m so sorry!” She turned her music down slightly and I resumed studying. But at that point, I was

experiencing a new distraction: I could not overcome my amazement at how painfully loud her music

was, and how she seemed genuinely surprised that I not only could hear her music, but I could hear it

from across the room. A disturbing realization that had long been a suspicion lurking in the back of my

mind set upon me: people like the girl in the silent room are damaging their hearing, without even

realizing it. And these people are not few and far apart: they are ubiquitous.

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Following this incident, I began to pay special attention to how many people around me wore

headphones, and noticed that I could usually hear their music over background noise, even when on

buses. A recent article by Lisa Belkin, who writes about family matters for the New York Times,

confirmed my suspicion that this was symptomatic of a problem: “When anyone else can hear your

music, the volume is too loud” (Belkin). Since headphone users are playing their music loudly enough

so that it is audible from across rooms, they are putting themselves at risk for permanent hearing loss,

and by doing this en masse, they may be poising the United States for a hearing loss epidemic. In this

paper, I will discuss how the safety of portable music devices and headphones is an urgent issue, and

how public education campaigns appear unlikely to improve hearing health behaviors to a satisfactory

extent. I will propose as an alternative to public education campaigns imposing laws upon

manufacturers that control the safety of portable music devices and headphones.

Why Change is Needed

The safety of portable music devices and headphones is a pressing issue because millions of

users are endangered by the products, those who are most at risk are young and will have to live with

the effects of hearing loss for decades, and hearing loss is preventable. Most people can testify to

seeing people use headphones and portable music devices everywhere, which confirms the prevalence

the products. The danger posed to the users by portable music devices is due to the volume output of

these devices, which ranges from 60 to 120 decibels, which, to put it into perspective, is about the

range of a conversation to the siren of an ambulance (Kosecki). According to Jane Brody, a health

columnist for the New York Times, persistent exposure to sound at a volume of 85 decibels or greater is

widely accepted as conducive to hearing loss: “…workplace rules require hearing protection for those

exposed to noise above 85 decibels” (Brody). Users of portable music devices can expose themselves

to noise levels exceeding that which occupational safety standards require hearing protection for, and

by a significant margin: decibels are measured on a logarithmic scale, meaning that, “for every 10

decibels, sound intensity increases tenfold” (Brody). The consequence of this is that a portable music

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device with a maximum volume output of 120 decibels can produce a sound intensity well over 1000

times that which causes hearing loss. And according to the Children’s Hearing Institute, not only is

there potential for widespread noise-induced hearing loss, but it is occurring: “hearing loss among

children and young adults is rising in the United States…one-third of the damage is caused by noise”

(Brody). Excessive noise is causing hearing loss with increasing prevalence, and because they are so

widely used and can expose users to dangerous decibel levels, portable music devices and headphones

pose a significant risk to the hearing of Americans.

The safety of portable music devices and headphones is also an exigent issue because the

population that is most at risk for hearing loss resulting from their use consists of people in their teens

and twenties (Belkin). Aside from regular portable music device and headphone use, what make people

in their teens particularly vulnerable to hearing loss caused by portable music devices and headphones

are their listening habits. “Teens play their music louder than young adults; teens may think that the

volume is lower than it actually is” (Belkin). Teenagers have dangerous listening habits, and according

to The Children’s Hearing Institute, these habits have not been without consequence: “Hearing

specialists are reporting seeing teens with signs of noise-induced hearing loss that would not be

expected until middle age” ("The Children's Hearing Institute -- Hearing Health/Preserving Hearing.").

The dangerous listening habits of teenagers are already causing detectable damage, and it is significant

that the age group that is most impacted consists of people in their teens and twenties, as its members—

by virtue of being young—will have to endure decades experiencing the effects of hearing loss that

they sustain. The effects that they will experience will not be mild either, as “the damage makes it

difficult to hear high pitched sounds, including certain speech sounds and the voices of women and

children” (Brody). Such effects, especially when experienced for decades, are socially detrimental, as

they are hindrances to communication. In view of this, the dangers of portable music devices and

headphones must be reduced as much as possible to decrease the incidence of hearing loss, as hearing

loss has far-reaching, long-lasting consequences.

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What is most significant about hearing loss caused by portable music devices and headphones is

that it is preventable, making efforts to improve the safety of the products worth exerting. To develop

preventative measures, one must use as premises that the incidence of hearing loss is rising, and its

increase is attributed largely to excessive noise exposure (Brody). A corollary of this is that reducing

dangerous noise exposure can reduce the risk of noise-induced hearing loss. Due to the high volume

outputs and widespread use of portable music devices and headphones, the products are ideal targets

for implementing changes that reduce dangerous noise exposure and consequentially protect hearing.

Some, especially manufacturers, may argue that because noise exposure from portable music

devices is controlled by the users, improving hearing health should be their responsibility. This view,

however, is not constructive, as it focuses on who is to blame for the health consequences of using the

products, rather than what the most effective approach minimizing them is. While it is true that hearing

loss can be prevented if either the safety of the products is increased or users of the products use them

responsibly, leaving the risk of hearing loss in the hands of the users is not a viable option for

decreasing the incidence of hearing loss. This is because influencing the hearing health behaviors of

users would require an effective public education campaign, but the issue of hearing health does not

have the characteristics that issues successfully addressed through public education campaigns have

had. Historically, the success of public education campaigns that sought to promote or inhibit a

behavior have hinged on three variables: the receptivity of the public to the behavior change, the ease

with which the behavior could be modified, and the expense associated with the modification. Not

surprisingly, issues that required behavior changes to which the public was receptive to making, were

easily modifiable, and had little or no expense have been most responsive to public health campaigns,

while those that did not fulfill those criteria yielded fewer changes. I will now examine the issue of

hearing health in terms of these variables, and see how they compare to those of other issues that public

health campaigns have addressed—both successfully and unsuccessfully.

Public Receptivity

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First and foremost, in order for a public health campaign to effectively promote or inhibit a

behavior, the public must be receptive to the required behavior change. This requires two conditions:

first, the public must be eager for a solution to a problem, seeing the recommendations of the campaign

as answers; second, the desired behavior changes must not conflict with the values of the public. The

1954 polio vaccine field trials—in which over 1.8 million children participated in the testing of the

vaccine created by Dr. Jonas Salk for its effectiveness in preventing polio—serve as an example in

which the first condition has been met and resulted in the success of a public health campaign (“Polio

Vaccine Announcement”).

Prior to the vaccine field trials, polio outbreaks—beginning in 1916—had reached epidemic

levels in the United States, affecting victims “regardless of geographic region, economic status, or

population density (“Polio: Communities”). The indiscriminate occurrence of polio, along with the

occasionally permanent disability—such as paralysis—that resulted from it, generated “intense dread

and fear” and disruption within communities, which struggled to control its spread. Efforts to control

the spread of polio, however, were unsuccessful, as it was not even known how polio was transmitted.

It was, however, observed that polio affected mostly children, leading communities to issue bans such

as the following, posted on a tree outside a town: “CHILDREN UNDER 16 NOT ALLOWED TO

ENTER THIS TOWN” (“Polio: Communities”). Because polio terrorized communities and the

country, the public was willing to take any measure to prevent polio, so when Salk’s vaccine was ready

for testing, “over 1,800,000 children participated in the field trials, which were unprecedented in

magnitude” (“Polio Vaccine Announcement”). The fear that the public had of polio was so great that it

overcame the fear of the possibility that the vaccine might not work—or worse, could have disastrous

effects, as was the case in the 1935 trials of a vaccine created by Maurice Brodie and John Kolmer—

and it was this fear that allowed for the sudden, momentous change in public health: within two years

of the announcement of the success of the vaccine, “the incidence of polio in the U.S. [fell] 85-90%”

(“Polio: Timeline”).

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As the polio vaccine trials reveal, fear of the consequences of a health condition make the

public receptive to the messages conveyed by public health campaigns and catalyze change. But the

context of the issue of hearing health is not like that of polio: unlike polio, hearing loss is not a

dramatic condition that is devastating to individuals and communities, so it is not intensely feared.

Instead, it is a condition with a slow, subtle onset that is viewed as an expected part of aging. The

consequence of this is that the issue of hearing loss does not meet the first condition—the public is

searching for a solution to the problem—for public receptivity to a public health campaign regarding it.

The second condition that must be met in order for the public to be receptive to a public health

campaign that promotes or inhibits a behavior is that the desired behavior change must not conflict with

the values of the public. The importance of this condition is apparent in the context of polio

vaccinations, as while when they became available, the vast majority of the population of the United

States eagerly accepted them, but a small sector of the population—members of Amish communities—

refused to be vaccinated for religious reasons. This refusal resulted in “the last cases of wild (naturally

occurring) polio in the United States…in 1979 in four states, among Amish residents who had refused

vaccination,” which demonstrates the importance of agreement between values and health behaviors

(“Polio: Communities”).

In regards to the issue of hearing health, for some, there is a subtle conflict between values and

hearing health behaviors, as was revealed by a study exploring the efficacy of hearing education. The

results strongly suggested that due to the social values of adolescents, teaching students about hearing

and how it can be lost does little to influence their listening habits: “The only change that occurred in

accordance with the purpose of the campaign…was an increase in the number of regeneration breaks at

the discotheque…In our opinion, the view expressed by several health experts, namely that adolescents

could be persuaded to protect their hearing if they were adequately informed or educated, is too

optimistic” (Weichbold, Viktor, and Patrick Zorowka). Not only does the study cast doubt on whether

hearing education programs are worth investing in, but it also states that the willingness of students to

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alter their listening behaviors is limited, as they may be knowledgeable of the dangers they subject

themselves to, “but this knowledge is outdone by a much stronger motivation to experience fun,

excitement, relaxation, companionship, approval from peers, etc.” (Weichbold, Viktor, and Patrick

Zorowka). In other words, the social environments of adolescents may reinforce hearing health

behaviors that oppose those promoted in hearing education, undermining the educational efforts.

By demonstrating how adolescents will knowingly put themselves at risk for hearing loss

despite their awareness of the consequences, the authors of the study reveal that many adolescents have

social values that conflict with practicing protective hearing behaviors: “going to discotheques, pop

concerts, or noisy parties is part of the adolescent lifestyle…and the forces behind these practices (e.g.

peer group pressure) are stronger than those induced by information” (Weichbold, Viktor, and Patrick

Zorowka). While this conflict between values and health behaviors is more negotiable than was that

between the religious values held in Amish communities and the need for polio vaccinations, it is

nonetheless an obstacle in reducing the incidence of noise-induced hearing loss, as it is a hindrance to

the receptivity of youths to changing hearing health behaviors. Because of this obstacle, neither the first

nor second conditions necessary for public receptivity to a hearing health campaign are met, which

strongly questions whether a hearing health campaign would be worthwhile. I will now consider the

ease with which hearing health behaviors can be modified, using examples of previous campaigns that

sought to influence behaviors that are both simple and difficult to change to predict the success of a

hearing health campaign.

Ease of Modifying Behavior

Public health campaigns may succeed in educating members of the public about a health issue,

and perhaps even in motivating them to improve certain health behaviors, but that does not mean that

the public will actually change their behaviors (“NINDS: Stroke Proceedings: Maibach”). This

“discontinuity between knowledge, attitude, and behavior change” has long been noted by health care

8

professionals, and the determining factor dictating whether there will be a translation from motivation

or attitude to behavior change appears to be the ease with which the behavior at issue can be modified

(“NINDS: Stroke Proceedings: Maibach”). The “Back to Sleep” campaign, a public health campaign

launched in June, 1994 in the United States that sought to reduce the incidence of Sudden Infant Death

Syndrome (SIDS), is an example of a public health campaign that successfully bridged the gap between

the motivation and behavior change of the public, as it required only a simple change: placing infants

on their backs instead of stomachs when putting them to bed (“Back to Sleep Campaign”). In the

decade following the Back to Sleep campaign, the rate of SIDS decreased from 1.03 deaths per 1000

live births, to 0.51, a marked decrease which Duane Alexander, the director of the National Institute of

Child Health and Human Development viewed as a “direct result of the Back to Sleep Campaign”

(“U.S. Annual SIDS Rate per 1000 Live Births,” “Back to Sleep Campaign”).

But modifying the health behaviors of the public is not as easy when the desired behaviors are

difficult to perform, as was noted in the article, “Why Education Won’t Solve the Obesity Problem,”

which appeared in the American Journal of Public Health in April, 2009 (Walls). In the article, the

authors—citing research on decision-making—argue that increasing the number of healthy food

options does little to benefit the public, as when “the number of choices increases, it becomes

increasingly difficult to evaluate attributes and select the best option” (Walls). In the context of healthy

eating, consumer confusion results when it is unclear what choices are healthy and what are not, and

the consequence of this is that consumers may make unhealthy food choices even when trying to

practice healthy eating habits that they learned from public health campaigns (Walls).

Like the issue of obesity, hearing health appears unlikely to be influenced by a public health

campaign, as it depends on behaviors that are not easily changed, since users of headphones and

portable music devices can abuse the products without knowing. This is because users may not realize

how loud the volume of their music is, as a brochure, included with a Sony voice recorder with

headphones and issued by the Consumer Electronics Association, warns: “Over time your hearing

9

‘comfort level’ adapts to higher volumes of sound. So what sounds ‘normal’ can actually be loud and

harmful to your hearing” (Consumer Electronics Association). As the brochure packaged—for liability

purposes, no doubt—with the voice recorder and headphones reveals, users of portable listening

devices and headphones can damage their hearing unwittingly. This is because unlike in the case of the

“Back to Sleep Campaign,” in which a baby is either sleeping in the correct or incorrect position, safety

in the context of decibel levels is not black and white; rather, it is a spectrum, and it can be difficult to

distinguish safe from unsafe. This issue is partially addressed by headphones with additional hearing-

safety features, but they are not widely used, as they cost substantially more than headphones that lack

such features. This brings me to the third variable that affects the success of a public health campaign:

the expense associated with the desired behavior modification.

Expense Associated with Behavior Modification

The expense associated with a behavior modification can be a limiting factor to how widespread

the modification becomes, and consequentially to the success of a public health campaign focused on

the behavior. In other words, health behaviors depend on finances, as is asserted in, “The High Cost of

Cheap Meals,” an article warning that the current economic recession will increase the incidence of

obesity, since healthy foods are more expensive than unhealthy ones: “But one of the most insidious

health effects of a downturn is in the area of diet. Eating healthily can be expensive and time-

consuming” (Summers). Poor diets do not immediately produce visible symptoms, and they are

consequences of economic downturns, as unhealthy foods are less expensive than healthier foods: “‘If

you and I went to Hale and Hearty [a New York chain] to have soup and salad, it would take us $30 to

be filled. If you go to McDonald's, we're going to be full for $6 each’” (Summers). Healthy foods tend

to be less filling and more expensive than those that are unhealthy, which is why public health experts

predict that the obesity rate in the United States will rise as a result of the recession (Summers). And

evidence that the public is reverting to cheap, unhealthy foods is already apparent, as McDonalds “has

defied the worldwide economic downturn, posting a first-quarter profit of $980 million, up 4 percent

10

from last year” (Summers).

As is the case with healthy eating, hearing health is often considered less important than

finances: the risk of hearing loss can be reduced, but for a cost that most people do not want to pay.

The risk at issue arises when users of headphones and portable music devices listen to music and

increase the volume to hear over background noise. This is a common practice addressed in “Healthy

Listening,” an article informing readers how to prevent hearing loss: “Switch over to a pair of sound-

isolating earphones; they drown out background noise so your music doesn’t have to” (Kosecki). Not

only can users of portable music devices and headphones damage their hearing by listening to music

loudly because of ambient noise, but they can reduce their risk of doing so by using noise-cancelling or

sound-insulating headphones. However, many people choose not to purchase these headphones, as they

are more expensive than others without noise-cancelling or sound-insulating features.

A Better Approach

Because hearing education is not a dependable—or perhaps even slightly influential—approach

to reducing the incidence of hearing loss, eliminating the primary problems—that is, the dangers posed

by portable music devices and headphones—at their sources by imposing strict safety regulations upon

manufacturers is the best approach to decreasing the incidence of hearing loss. Reducing the dangers of

portable music devices can be accomplished by enacting laws prohibiting manufactures from producing

portable music devices with hazardous decibel outputs, and by requiring producers of headphones to

include safety features such as noise-cancelling or sound-insulating technology in the products. Such

regulations would not only provide safer products to the public, but they would overcome the obstacle

of safer products being financially inaccessible. This is because when the safer products are sold

exclusively—since products that do not meet the new safety standards would be illegal to sell, pushing

them off the market entirely—retailers would be forced to offer them at affordable prices.

Once a consensus among legislators is reached that new safety regulations for portable music

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devices and headphones must be passed and enforced—as opposed to directing funds to hearing

education programs—the debate will shift to what specific regulations must be made, with decibel

output regulations and noise-cancelling and sound-insulating technology being only a few possibilities.

This matter will require a collaboration of otologists, otolaryngologists, audiologists, technology

developers, and legislators, and regulations will likely require tweaking over time as technology

continues to advance, and research on hearing accumulates. Improving the safety of portable music

devices, headphones, and the public as a whole is—due to developing technology and ongoing research

—a process, rather than a single action, and it is a process that, because of the high stakes since the

incidence of hearing loss is rising, must begin immediately.

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