Prevalence of loud leisure noise activities among a representative sample of Canadians aged 6–79 years

The cumulative effect of excessive noise exposure experienced during everyday activities may contribute to noise-induced hearing loss (NIHL). Occupational noise exposure is a commonly identified source with 16% of disabling adult hearing loss attributed to workplace noise worldwide (Nelson et al., 2005). However, some studies of young construction or trade workers have reported high prevalence rates of hearing impairment prior to employment (Rabinowitz et al., 2006), leading to the premise that non-occupational noise exposure may also be a significant contributing risk factor (Leensen et al., 2011). Evaluating the prevalence and number of times that individuals engage in loud leisure noise activities can offer insight into the risk to hearing that may be associated with this type of exposure. Studies have shown low hearing protection usage among participants engaging in high noise leisure activities and limited knowledge regarding mitigation strategies (Gilles et al., 2013; Nondahl et al., 2006).

Although workplace hearing conservation programs include education, regular hearing tests and messaging to increase employee awareness of hazardous noise exposures, reducing one's risk to leisure noise requires awareness regarding how the sound pressure level (SPL) and duration of exposure act together to create a risk to hearing, and how this risk may be mitigated. An awareness of the hazard needs to be combined with a motivation to take the necessary steps toward reducing potentially harmful noise exposures, both in the workplace and during leisure activities. Furthermore, some studies have shown that many individuals may take part in multiple noisy leisure activities (Le Prell et al., 2011; Dalton et al., 2001); nearly one-third of college students reported three or more noisy leisure activities (Le Prell et al., 2011), and 91% of older adults engaged in two or more noisy leisure activities (Dalton et al., 2001). Last, a study of young adults found that individuals who took part in one noisy leisure activity were more likely to engage in others (Beach et al., 2013). Multiple loud leisure noise sources may further increase the risk of hearing impairment from leisure noise exposure.

Under certain usage conditions, personal listening devices (PLDs) used with earphones may be hazardous to hearing as they can reach continuous equivalent SPLs as high as 126 dBA (Keith et al., 2008; Breinbauer et al., 2012). Effects may include threshold shifts and/or the development of tinnitus, both of which have been associated with an increased risk of depression, anxiety, and lower quality of life ratings while hearing impairment alone has been linked to cognitive decline and social isolation (Fortunato et al., 2016; Langguth, 2011; Li et al., 2014; Vogel et al., 2014). Nightclubs and concerts are another common source of hazardous leisure noise; reported sound levels for nightclubs range from 104.3 to 112.4 dBA (Serra et al., 2005) with an average level of 97.9 dBA (Williams et al., 2010). Other leisure activities that have been associated with SPLs above 90 dBA include woodworking/carpentry activities, playing in a music band, attending music venues or sporting events, fireworks, recreational firearm activities, and riding recreational vehicles such as snowmobiles or motorcycles (Dalton et al., 2001; Opperman et al., 2006; Meinke et al., 2017; Serra et al., 2005).

In the absence of a personal dosimeter, estimating the SPL and associated risk to hearing from leisure noise can be difficult. One method used to define hazardous occupational noise is based upon self-reported vocal effort (Tak et al., 2009). This method evaluates the need to speak in a raised voice in order to communicate with someone standing at arm's length distance, which is equivalent to the minimum degree of vocal effort when extrapolated to background noise levels around 85–90 dBA (Levitt and Webster, 1991). Vocal effort alone cannot be used to estimate PLD sound when paired with noise-isolating earphones, which can impede communication regardless of the ambient SPL. For this reason, the present study used volume level settings, in addition to vocal effort, to define loud PLD usage. Research has shown that a 50% volume level setting may be regarded as having no adverse impact on hearing (Breinbauer et al., 2012), while a three-quarter volume level setting or higher has been associated with more “risky” listening behaviour, as these high volume settings and concomitant SPLs have been associated with some degree of measured hearing loss or higher mean hearing thresholds at some frequencies (Feder et al., 2013; Kumar and Deepashree, 2016; Taneja et al., 2015).

The definition of loud used in this study, which was needing to speak in a raised voice to be understood by or communicate with someone standing an arm's length away, except for PLD usage where loud was also defined by a volume setting level at or above three-quarters of the maximum volume, screened out participants that were not likely exposed to hazardous noise. However, this approach is not sensitive enough to yield estimates of the prevalence of a population that may be at risk for NIHL because of the variation that can exist between each activity's typical SPL. To account for these variations, a noise weighting factor for each loud leisure noise activity, as well as self-reported noise durations, may be used, allowing estimates of individuals potentially at risk of developing NIHL when noise exposure exceeds a common occupational limit of 85 dBA for a 40 hour work week, denoted as 85 dBA (LEX, 40 h). To date, there are no population-based studies estimating potentially hazardous leisure noise among a representative sample of Canadians and how many may be at risk for developing NIHL. It is also unknown how participation in different loud leisure activities varies by age, sex, education, or income level. The present study addressed these knowledge gaps by evaluating the prevalence of loud noise exposure from leisure activities and using a common occupational noise limit as a guide, estimating the prevalence of those at risk of developing NIHL among a nationally representative sample of Canadians, aged 6–79 years.

Individuals completed a household questionnaire as part of the Canadian Health Measures Survey (CHMS) with a response rate of 89.6%. Proxy interviews were accepted in cases of physical and/or intellectual impairment and for children under age 12. Household in-person questionnaires consisting of sociodemographic and noise questions were administered to participants, aged 6–79 years. The final analysis comprised 10 460 participants (49.9% males), representing approximately 30.8 × 10⁶ Canadians. This study was approved by the Health Canada and Public Health Agency of Canada Review Ethics Board (Protocol No. 2005-0025).

The CHMS is an ongoing national survey, conducted every two years, which collects information on Canadians' health and health habits. The CHMS is the most comprehensive, direct health measures survey conducted in Canada and designed to represent the Canadian population. This survey includes personal in-home interviews and the collection of physical measurements, conducted in a mobile examination clinic. Baseline data are collected on indicators such as environmental exposures, chronic and infectious diseases, fitness and nutritional status, among others; physical measurements include height, weight, blood pressure, physical fitness, lung function, blood, urine and saliva samples, among others. Hearing tests and noise exposure questions were added to the CHMS for the first time in 2012 with data collection over four years (2012–2015, cycles 3 and 4). The analysis shown is the first time that leisure noise exposure data have been presented.

Recruitment of CHMS cycles 3 and 4 participants took place between January 2012 and December 2015 across five regions of Canada: Atlantic, Quebec, Ontario, Prairies, and British Columbia. In this ongoing cross-sectional survey, one or two individuals were randomly selected from each household using a multistage weighted person-level sampling strategy by age and sex. The CHMS excludes full-time members of the Canadian Forces, residents of the three territories, First Nations Reserves, and other Aboriginal settlements, certain remote regions, and institutional residents. Despite these exclusions, CHMS data are considered to be representative of the Canadian population as this sampling protocol covers approximately 96% of the Canadian population (Statistics Canada, 2015).

Self-reported data were collected in-person at the participant's home, in English or French, using a computer-assisted personal interview, which is designed to prevent invalid data entry (Statistics Canada, 2015). Potentially hazardous leisure noise sources were estimated by asking participants if they participated in loud activities during the previous year, including activities that took place at work, at school, or during leisure time. Participants were asked to indicate the number of times and duration each time they used or were exposed to the following sources in the previous 12 months: power tools (e.g., circular saws, grinders, belt sanders, hammer drills); heavy industrial, farming or construction equipment (e.g., bulldozers, gas turbines, large compressors); hand-held gasoline engines (e.g., leaf blowers, hedge trimmers, gas-powered chainsaws); motorcycles or snowmobiles driven at highway speeds; sporting or entertainment events such as hockey; amplified music at concerts, nightclubs, or as a band member; other types of music without the use of headphone/earphones such as a home or car stereo; and last, firearms or guns. Participants were also asked if they used hearing protection while participating in each activity.

PLD usage with headphones or earbuds, which included MP3 (digital audio files) players, iPods (Apple, Cupertino, CA), cell phones, stereo systems, televisions or computers, used to listen to music, movies, or other types of audio were also evaluated. Participants who used PLDs in the previous 12 months were asked to estimate how many hours per week they listened to their device and indicate whether they listened to their PLD at loud volumes. Individuals who replied affirmatively to listening to their PLD at loud volumes were then asked how long they used this setting as their usual listening volume. This information allowed years of loud PLD listening to be captured. The CHMS noise exposure component questions can be accessed online.¹

Participants were informed that an activity was considered loud if they needed to speak in a raised voice to be understood by or communicate with someone standing an arm's length away. In the case of PLD usage (i.e., listening to music, movies, or other types of audio devices using headphones or earbuds), loud was also defined by a volume setting level at or above three-quarters of the maximum volume.

Leisure noise exposure classification categories were based on participants' self-reported duration of exposure to various activities, each of which were assigned average SPLs considered to be consistent with published literature (Dalton et al., 2001; Flamme et al., 2009; Kennedy et al., 2013) and the current study's definition of “loud” noise exposure. Participants were assigned to the high category if their calculated noise exposure was equivalent to (or above) the occupational limit of 85 dBA (LEX, 40 h; ISO, 2013). The low category represents a noise exposure at or below 75 dBA (effective quiet), and the medium category was selected to be exclusive of the high and low. Table I identifies the calculated thresholds by time or rounds fired/exposed to per week, delineating the high, medium, and low leisure noise exposure categories. Using equal energy, the noise weighting factors (rounded to the nearest integer) shown in Table I were used to account for exposures to activities with different average SPLs. Specifically, self-reported participation in the various loud leisure activities was used to calculate a weekly exposure duration in hours. In the case of firearms, the estimated number of rounds fired or exposed to were converted to equivalent hours per round before calculating hours per week, which resulted in a weighting factor of 8 for this activity. This calculation is based on a single round being equivalent to 85 dBA, LEX, 8 h, or 20% of the weekly dosage, with 5 rounds per week approximating 85 dBA, LEX, 40 h (Table I, footnote h). The weekly values for each loud leisure activity were multiplied by the corresponding noise weighting factor in order to classify participants into the appropriate leisure noise exposure category.

An individual's total duration, in hours per week, was calculated for each noisy leisure activity using the self-reported information participants provided. Participants who responded affirmatively to taking part in a specific noisy leisure activity during the previous 12 months were then asked how often, i.e., how many times, they engaged in this activity during the previous 12 months. They were further asked to indicate the amount of time they spent during each occasion, using the following category options: less than 10 min, 10 min to less than 30 min, 30 min to less than 1.5 h, 1.5 h to less than 5 h, 5 h or more. The midpoint of each time interval (in minutes) was multiplied by the total number of times the individual reported participating in or being exposed to a noisy leisure activity during the previous year. In the case of the last time interval (5 h or more), the midpoint was chosen to be 8 h (480 min). This was divided by 60 min per hour and 52 weeks per year in order to yield an estimate of the hours per week spent taking part in each noisy leisure activity. The self-reported times were multiplied by the appropriate noise weighting factor (Table I) in order to classify an individual's leisure noise exposure level for each source. A resulting noise exposure at or above the occupational limit of 85 dBA (LEX, 40 h) was categorized as high (40 h per week or more) or medium (greater than 4 to less than 40 h per week), and a noise exposure of 75 dBA (LEX, 40 h) or less (4 h or less per week) was categorized as low noise exposure, as shown in Table I.

For firearms, respondents identified the number of rounds fired or exposed to in the previous 12 months in one of four provided categories. The number of rounds fired refers to the participants' own use of the firearm, whereas the number of rounds an individual was exposed to refers to firearm noise exposure that a participant was exposed to as a bystander. This question was posed in this manner as a means of capturing both types of exposures. The midpoint was selected for the two lowest categories (i.e., 1–19 and 20–99), however, 1000 was arbitrarily selected as the “midpoint” for the 100–9999 category based on an assumed 3 rounds/day exposure. Similarly, for the highest category (i.e., 10 000 or greater), 10 000 was selected as the “midpoint.” The midpoint number of rounds in the previous 12 months was converted to a weekly number of rounds and classified as high, medium, or low, similar to the description above (Table I). To calculate the cumulative noise exposure, participants' total time (in hours per week) for each loud leisure activity was multiplied by the appropriate noise weighting factor and then summed across all activities. The cumulative time at an average of 85 dBA SPL was classified as low (4 h or less per week), medium (greater than 4 h to less than 40 h per week), or high (40 h/week or more).

Population weighted frequencies and cross-tabulations were used to explore leisure noise characteristics (e.g., PLD usage duration and listening volume, using headphones/earbuds) by demographic variables (age, sex, education, income, CHMS cycle). All estimates were weighted at the person level to represent the population. The population weighting procedure carried out was based on the principle that the individual selected in a probability sample, such as the CHMS, “represents” himself or herself in addition to several other individuals not in the sample. The weighting procedure that was applied corresponds to the number of individuals represented by the participant in the population as a whole. Therefore, the weighting, which takes into account the age and sex distribution of the population, non-response, and the sampling strategy of the survey, allows frequency calculations that are representative of the population. See the CHMS user guide for further details about the weighting procedure and its application (Statistics Canada, 2015).

Analyses were conducted using sas software Enterprise Guide 7.15 for Windows (SAS Institute Inc., Cary, NC) and SUDAAN 11.0.0 software (Research Triangle Institute, Research Triangle Park, NC). To account for the complex survey design, p-values, 95% confidence intervals, and coefficients of variation (CVs) were estimated using the bootstrap technique with 22 degrees of freedom (Rao, 1992; Rust and Rao, 1996). Statistical significance was specified as a p-value of less than 0.05. All comparisons were carried out using the Satterthwaite F test, and Bonferroni corrections were made where multiple pairwise comparisons were carried out. Estimates with a CV between 16.6% and 33.3% were designated “E” and are to be interpreted with caution due to the high sampling variability associated with it; CV estimates that exceeded 33.3% were designated “F” indicating that these data could not be released due to questionable validity. Note that the designations for “E” and “F” are denoted differently in Tables II–VII, as indicated in the table footnotes. Most of the results for PLD usage are presented separately from other leisure noise activities because of the widespread interest in this particular class of leisure noise.

Table II shows that the most prevalent loud leisure activities reported during the previous 12 month period were from amplified music (concerts/nightclubs/band member), power tools, and car/home stereos. Among all Canadians, loud PLD usage (any volume) was reported by 19.5% of participants. The demographic variables age, sex, household education, and household income by the number of loud leisure activities engaged in over the previous 12 months are reported in supplemental Table S1.²

The use of hearing protection varied considerably across leisure noise sources (Table II). The highest hearing protection usage was reported during firearm use (44.2%). The lowest prevalence of hearing protection usage was reported by individuals exposed to amplified music and sporting/entertainment event noise where the prevalence rates were 2.5^E% and 1.9^E%, respectively.

The pattern of PLD prevalence among participants aged 6–79 years, regardless of volume or duration, was as follows: at age 6 years, approximately one-third (29.1%) used a PLD with prevalence nearly doubling by age 9 years (59.8%), reaching a prevalence of 80.7% by age 12 years; PLD usage remained high among 12–19 year olds (85%–95%), with a decrease in prevalence observed after age 20 years (72.5%; Fig. 1). Detailed findings related to the prevalence of PLD usage are provided as supplemental material.²

Nearly half of all Canadians (44.2%), aged 12–19 years, reported loud PLD usage. Among children under the age of 12 years, approximately one out of eight reported using their PLD at loud volumes (Table III). A significant difference was observed by sex, with more males using PLDs at loud volumes; no difference was seen by household education level or income (Table III).

Table IV provides the statistical distribution of PLD (any volume) and loud PLD usage along with how many years participants reported to have listened to PLDs, specifically at a loud volume setting. The median PLD listening time at a loud volume was just under 3 h per week with a wide range of between 0.5 and 91 h per week reported; nearly one-third reported listening durations above the arithmetic mean.

As seen in Table V, significantly more males than females reported engaging in each loud leisure noise activity, with the exception of amplified music. Overall, participants aged 12–19 years and 20–39 years had a significantly higher prevalence of loud leisure noise exposure for the majority of sources compared to other age groups, with the exception of noise from power tools, gasoline engines, and heavy industrial farming machinery, for which the majority of participants were aged 20–39 years and 40–59 years.

Table VI shows males were also more likely to participate in two or more noisy leisure activities compared to females (65.5% vs 45.1%). Individuals aged 12–19 years and 20–39 years had significantly higher prevalence rates for participating in two or more loud leisure activities compared to all other age groups. Participants from households with an annual income greater than $100 000 had a significantly higher prevalence of participating in two or more loud leisure activities compared to those from lower household incomes. The full distribution for the number of participants that reported engaging in 1–8 or more loud leisure noise activities is shown in supplemental Fig. S1.²

Among respondents who replied affirmatively to loud leisure noise at the outset, the prevalence values for high leisure noise exposure categories, in addition to medium and low exposure categories, are reported in Table VII. The prevalence of Canadians engaging in loud leisure noise activity and classified as being in the high leisure noise exposure category (i.e., an exposure duration equivalent to a 40 h work week at or above 85 dBA) ranged from 3.9% for gasoline engines to 31.8% for motorcycles/snowmobiles driven at highway speeds. However, it should be noted that the majority of participants reported no exposure to certain loud leisure noise activities. For example, nearly 88% were not exposed to motorcycle/snowmobile noise when driven at highway speeds, and 76% were not exposed to gasoline engine noise. The results for listening to loud music without headphones or earbuds and exposure to loud sporting/entertainment event noise were too unreliable to report because after considering weekly hours of usage, too few participants showing large response variability were in the highest noise exposure categories. The prevalence of reported hearing protection usage was more common among the high exposure categories. Last, 28.5% of participants who reported exposure to loud leisure noise activities, representing an estimated 6.6 × 10⁶ Canadians, were found to be in the high cumulative leisure noise category when loud leisure noise from all sources was considered (Table VII).

Evaluation of two CHMS sampling cycles spanning a period of time between 2012 and 2015 has shown that the most prevalent loud leisure noise activities among Canadians were amplified music (e.g., concerts, nightclubs), power tools, or listening to loud music without headphones or earbuds (e.g., stereo system, car radios). Firearms, industrial farming/construction equipment noise, or motorcycle/snowmobile at highways speeds were each less prevalent (i.e., <16%). No differences were observed across CHMS cycles 3 and 4, suggesting stability in the reported findings.

The results are generally consistent with those reported elsewhere. Specifically, amplified music from nightclub, public house, and live concert attendance has been identified as a common source of leisure noise for teenagers and young adults in several studies (Beach et al., 2013; Degeest et al., 2017; Gilles et al., 2012; Moore et al., 2016). In an Australian study of young adults, aged 18–35 years, the authors speculated that nightclub attendance was likely the “major culprit” in terms of accumulated noise for many young people (Beach et al., 2013). It is clear from the current study that, in addition to amplified music, teenagers and young adults reported a higher prevalence of participation than other age groups to a variety of leisure activities that are associated with high noise levels.

The present study found that nearly half of all Canadians used PLDs, and among teenagers (12–19 year olds), 91.2% reported using PLDs. A high prevalence of PLD usage was also observed among young school-aged children, with an upward trend observed beginning at age 6 years up until age 12 years. As with all noise, SPL and duration are key determinants of risk. Among Canadians under age 12 years, one out of eight children used their PLD at loud volumes according to parent or guardian's proxy reports. There have been two PLD studies involving young children to date: a Swedish study of 9 year olds by Basjo et al. (2016), and a larger study involving 9–11 year olds by le Clercq et al. (2018). Disparities in study design make it difficult to compare findings; however, these studies and the current study confirm the popularity of PLDs among young children.

The prevalence of loud PLD usage observed among teenagers in the present study (44.2%) is in keeping with findings reported by Vogel et al. (2009) involving adolescents, where 48% listened to their PLD at high volume settings, in addition to studies involving college students or young adults where approximately one-third of PLD users listened to music above 80 dBA for 8 h or at full volume (Hoover and Krishnamurti, 2010; Kumar et al., 2009). An Australian PLD user study found that approximately 15% were at risk of hearing damage from self-reported high listening volumes and excessive listening durations, with a greater percentage of younger participants, aged 18–35 years, in the higher risk categories (Gilliver et al., 2017).

NIHL can result from very high instantaneous SPLs and/or from cumulative noise exposures over time. However, cumulative high noise exposure is difficult to determine in individuals, whose leisure habits, preferences, and behaviours can change throughout childhood and adolescence to adult years. The present study indicates that while just over one-third of Canadians (34.3%) reported loud car or home stereo listening, very few were listening at durations which would place them in the high noise category, suggesting this source alone may not be a significant contributor to total leisure noise. Amplified music was found to be a substantial leisure noise source among adolescents (48%) and young adults (60%), with approximately 20% in the high noise category when self-reported duration was considered, suggesting this may be a significant contributor to total leisure noise. The present study finding that engaging in three or more loud leisure noise activities during the previous 12 months was more prevalent among teenagers/young adults in comparison to other age groups suggests that total leisure noise exposure may be excessive for this demographic.

Considering all sources and durations of loud leisure noise in this study, and using a common occupational limit, approximately 28.5% of respondents who reported loud leisure noise were in the high cumulative leisure noise exposure category. This corresponds to 6.6 × 10⁶ Canadians who would potentially be at-risk for developing NIHL should their noise exposure pattern persist over time. The degree of hearing loss or impact on the auditory system is dependent on the number of years of high leisure noise exposure, as well as other factors, including but not limited to age, sex, and history of occupational noise exposure. The categorization approach used in the present study allowed the prevalence of individual sources of high noise to be identified while also allowing a summation across all activities. Although an individual may be in the low or medium noise category for specific leisure activities, when cumulative leisure noise was estimated, this individual may be in the high noise category. The high cumulative leisure noise category therefore represents important information as it provides a snapshot of potentially hazardous leisure noise across all activities, estimated from self-reported durations for the previous 12 months. Using the occupational limit of at or above 85 dBA (LEX, 40 h), one may speculate about the potential consequences on hearing health should such a pattern continue over years.

There are no other population-based studies to date examining cumulative leisure noise exposure; however, some studies have been conducted on specific age groups or leisure activities, using differing methods to quantify long-term noise exposure from non-work and leisure activities (Williams et al., 2010; Neitzel et al., 2004; Dehnert et al., 2015). One such cumulative leisure noise exposure study involving Finnish conscripts (n = 1054) reported that one-third had weekly noise exposures of greater than 85 dBA, and 20% had hearing loss thresholds of greater than 20 dB (one or more frequencies, 0.5–8 kHz; Jokitulppo et al., 2005). Future studies examining the association between cumulative leisure noise exposure and hearing thresholds may be beneficial.

Overall, males had a higher prevalence of participation in loud leisure noise activities with the exception of amplified music, in which no sex differences were observed. Consistent with the present findings, several studies found a higher prevalence of males listened to PLDs at loud volumes (McNeill et al., 2010; Torre, 2008; Vogel et al., 2010), while others reported no significant sex differences in terms of PLD listening volumes or duration (Fligor et al., 2014; Levey et al., 2011).

Contrary to our findings showing no difference in highest household education level among loud PLD users, one adolescent study found that pre-vocational school attendees were nearly 2.5 times more likely to listen to high volume PLD music compared to their pre-university counterparts, in addition to reporting greater exposure to potentially hazardous music levels from discotheques and pop concerts (Vogel et al., 2011). Similarly, another adolescent study found that attending vocational school, being in a single parent household, and low parental education were associated with high PLD volume and duration usage (Twardella et al., 2017). In a longitudinal study of adolescents/young adults, Dreher et al. (2018) reported that, in addition to coming from a two-parent household, having 12 years of education was associated with safer PLD listening behaviour and lower total leisure noise. These differences in study findings may be due to the broad age range comprising a nationally representative sample in the present study, compared to the sample of 12–19 year olds from Dutch secondary schools (Vogel et al., 2011) and the Bavarian sample of 9th grade students (Dreher et al., 2018; Twardella et al., 2017).

In the present study, individuals from high income households ($100 000 or more) and those with some post-secondary education or higher (at the household level) were more likely to report amplified music as a leisure noise source. The increased prevalence among those from high income households may be due to the cost of attending concerts, festivals, and going to nightclubs. Beach et al. (2013) found an association between education and concert attendance, such that that those holding a trade or university qualification spent more time at concerts, and surmised that perhaps higher educational attainment was related to greater disposable income for attending concerts, a postulate that may also apply to the present study finding.

The risk of NIHL can be reduced by using appropriate hearing protection. In the present study, hearing protection usage for the majority of leisure noise activities was low overall, with the lowest usage reported for sporting/entertainment events and amplified music (less than 3%). The highest usage was reported while using firearms (44.2%) followed by farming/construction equipment operations (29.6%), gasoline engines (21.9%), power tool noise (20.3%), and motorcycle/snowmobile noise (14.1^E%). However, it is encouraging that an increased prevalence in hearing protection usage was observed as the noise exposure classification increased from low to high. The present study findings with regard to hearing protection usage are generally consistent with those reported by others (Nondahl et al., 2000; Nondahl et al., 2006; McCombe and Binnington, 1994; Dalton et al., 2001; Stewart et al., 2014; Widen and Erlandsson, 2004). It should be noted that while hearing protection usage is known to be effective in attenuating excessive noise when properly fitted, it is likely that a certain percentage of the sample were not properly using their hearing protection either due to lack of knowledge or poor fit (Health and Safety Executive, 2009; Nélisse et al., 2012). Therefore, one may speculate that the prevalence of effective hearing protection usage may be lower than reported in the current study. The scope of the present study precluded questions regarding hearing protection type, fit, and knowledge of usage. These factors would have allowed for more precise adjustments of actual noise exposure among individuals reporting hearing protection usage during noisy leisure activities, and allowed an improved estimate of the percentage of the population exposed to high leisure noise. Future research addressing the uncertainty related to hearing protection usage would be beneficial.

As the first population-based study to evaluate self-reported participation in loud leisure noise activities, these findings offer insight into the sources that may be most prevalent, such as amplified music, car/home stereo listening, and power tool noise, and clearly identifies the infrequent use of hearing protection. PLD usage with headphones or earbuds is unique in that sound is delivered directly into the ear, with loud volume listening over time representing a potentially hazardous source of loud leisure noise exposure. Among PLD users in the present study, loud volume listening for 6 h or more per week was reported by a high proportion of teenagers and young adults (46.8% of 12–19 year olds; 32.0% of 20–39 year olds; supplemental Table S3).² While not the most prevalent overall, loud PLD listening may represent a potentially hazardous leisure noise exposure for this demographic, depending on the number of years that this PLD listening behaviour were to continue.

The present study limitations should be considered when interpreting the findings, one of which is the collection of self-reported leisure noise exposure, particularly for PLD usage. Reliance on self-reported data has been discussed in the literature with some, but not all studies reporting significant differences between self-reported and objectively measured PLD output levels, leading some researchers to conclude that self-reported listening volumes and durations may be unreliable and underestimated (Portnuff et al., 2011; Widen et al., 2017). The exception being a small study of young adults (n = 24), in which self-report using a visual analog scale for usual PLD listening time and duration correlated fairly accurately with one week of logged dosimetry data (Portnuff et al., 2013); however, these results would need to be replicated using a larger sample size. There is an additional uncertainty associated with reliance on vocal effort to delineate when engaging in a leisure activity is associated with a noise that may be hazardous to hearing. Although the same limitation applies to PLD usage where both vocal effort and volume setting were used to define loud SPLs, this may be somewhat offset by the tendency for PLD users to underestimate their actual noise exposure level. Another limitation pertains to the range of leisure noise activities included in the survey and the fact that some loud activities, such as aerobic or fitness classes, were not specifically addressed in the survey. While an individual may have chosen to include this source under the sports/entertainment leisure noise categories or under stereo listening without headphones, it may not have been reported by study participants. Therefore, this exclusion may have resulted in total leisure noise exposure being underestimated for those that engaged in this or other loud leisure noise activities. There is also uncertainty regarding the SPLs assigned to specific loud leisure noise activities in this analysis. While best efforts were made to assign representative SPLs to each loud leisure noise, there is a margin of error associated with these values. Last, the authors acknowledge that for some sources, it cannot be firmly differentiated whether the noise was experienced during leisure time and/or in the workplace, due to the wording of the question. Industrial farming/equipment noise or hand-held gasoline engine noise may have been experienced in the workplace, particularly when lengthy durations were reported. However, for most of the noise sources evaluated, such as motorcycles or snowmobiles driven at highway speed, sporting or entertainment events, amplified music, car/home stereos, firearms, or PLD usage, there is a high probability that these were leisure noise exposures.

In summary, this study is the first to provide nationally representative estimates regarding the prevalence of high leisure noise exposure among Canadians, from both individual and cumulative sources. An estimated 6.6 × 10⁶ Canadians are exposed to a cumulative leisure noise level that is estimated to be at or above an occupational noise exposure limit that is intended to protect workers from NIHL. Although several years of participation in loud leisure noise activities may be needed for NIHL to manifest on an audiogram, further studies are needed to assess the strength of the association between high leisure noise exposures and audiometrically measured hearing acuity.

The authors wish to thank all of the individuals, including children and families, who took part in this study. This research was funded by Statistics Canada and Health Canada.