Health effects from noise

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More than a quarter of US residences have average outside noise levels exceeding the maximum nighttime outside noise level recommended by the World Health Organization. 20230609 Average noise levels outside US homes.svg
More than a quarter of US residences have average outside noise levels exceeding the maximum nighttime outside noise level recommended by the World Health Organization.

Noise health effects are the physical and psychological health consequences of regular exposure to consistent elevated sound levels. Noise from traffic, in particular, is considered by the World Health Organization to be one of the worst environmental stressors for humans, second only to air pollution. [2] Elevated workplace or environmental noise can cause hearing impairment, tinnitus, hypertension, ischemic heart disease, annoyance, and sleep disturbance. [3] [4] Changes in the immune system and birth defects have been also attributed to noise exposure. [5]

Contents

Although age-related health effects (presbycusis) occur naturally with age, [6] in many countries the cumulative impact of noise is sufficient to impair the hearing of a large fraction of the population over the course of a lifetime. [7] [8] Noise exposure has been known to induce noise-induced hearing loss, tinnitus, hypertension, vasoconstriction, and other cardiovascular adverse effects. [9] [10] Chronic noise exposure has been associated with sleep disturbances and increased incidence of diabetes. Adverse cardiovascular effects occur from chronic exposure to noise due to the sympathetic nervous system's inability to habituate. The sympathetic nervous system maintains lighter stages of sleep when the body is exposed to noise, which does not allow blood pressure to follow the normal rise and fall cycle of an undisturbed circadian rhythm. [3]

Stress from time spent around elevated noise levels has been linked with increased workplace accident rates, aggression, and other anti-social behaviors. [11] The most significant sources are vehicles, aircraft, prolonged exposure to loud music, and industrial noise. [12] Prolonged exposure to noise at home has been linked to decreased mental health. [13]

There are approximately 10,000 deaths per year as a result of noise in the European Union. [14] [15]

Noise induced hearing loss

An audiologist conducting an audiometric hearing test in a sound-proof testing booth HearingExam.jpg
An audiologist conducting an audiometric hearing test in a sound-proof testing booth

Noise-induced hearing loss is a permanent shift in pure-tone thresholds, resulting in sensorineural hearing loss. The severity of a threshold shift is dependent on duration and severity of noise exposure. Noise-induced threshold shifts are seen as a notch on an audiogram from 3000 to 6000 Hz, but most often at 4000 Hz. [16]

Exposure to loud noises, either in a single traumatic experience or over time, can damage the auditory system and result in hearing loss and sometimes tinnitus as well. Traumatic noise exposure can happen at work (e.g., loud machinery), at play (e.g., loud sporting events, concerts, recreational activities), and/or by accident (e.g., a backfiring engine.) Noise induced hearing loss is sometimes unilateral and typically causes patients to lose hearing around the frequency of the triggering sound trauma. [17]

Tinnitus

Tinnitus is an auditory disorder characterized by the perception of a sound (ringing, chirping, buzzing, etc.) in the ear in the absence of an external sound source. There are two types of tinnitus: subjective and objective. Subjective is the most common and can only be heard "in the head" by the person affected. Objective tinnitus can be heard from those around the affected person and the audiologist can hear it using a stethoscope. Tinnitus can also be categorized by the way it sounds in one's ear, pulsatile tinnitus [18] which is caused by the vascular nature of Glomus tumors and non-pulsatile tinnitus which usually sounds like crickets, the sea and bees.

Though the pathophysiology of tinnitus is not known, noise exposure can be a contributing factor, therefore tinnitus can be associated with hearing loss, generated by the cochlea and central nervous system (CNS). High frequency hearing loss causes a high pitched tinnitus and low frequency hearing loss causes a roaring tinnitus. [19] Noise-induced tinnitus can be temporary or permanent depending on the type and amount of noise a person was exposed to.

Cardiovascular effects

Noise has been associated with important cardiovascular health problems, particularly hypertension, as it causes an increase in levels of stress hormones and vascular oxidative stress. [2] [20] [21] [22] Noise levels of 50  dB(A) or greater at night may increase the risk of myocardial infarction by chronically elevating cortisol production. [23] [24] [25]

Traffic noise has several negative effects, including increased risk for coronary artery disease, with night-time exposure to noise possibly more harmful than day-time exposure. [2] It has also been shown to increase blood pressure in individuals within the surrounding residential areas, with railways causing the greatest cardiovascular effects. [26] [27] Roadway noise levels are sufficient to constrict arterial blood flow and lead to elevated blood pressure. [28] [26] Vasoconstriction can result from elevated adrenaline levels or through medical stress reactions. Long-term exposure to noise is correlated to increase in cortisol and angiotensin-II levels which are respectively associated with oxidative stress and vascular inflammation. [2] Individuals subject to great than 80 dB(A) in the workplace are at increased risk of having increased blood pressure. [29] [30]

A 2021 systematic review on the effect of occupational exposure to noise on ischemic heart disease (IHD), stroke and hypertension, coordinated by the World Health Organization (WHO) and the International Labour Organization (ILO) located 17 studies that met the inclusion criteria, comprising a total of 534,688 participants (7.47% females) in 11 countries and in three WHO regions (the Americas, Europe, and the Western Pacific). [31] The study found the low quality of evidence the effect of occupational exposure to intense noise (≥85 dBA), compared to occupational exposure below 85 dBA (<85 dBA). They concluded that there is an inadequate evidence of harmfulness for the studied outcomes with the exception for the risk of acquiring IHD, which was 29% higher for those exposed to noise in their workplace. [31]

Other physical health effects

Traffic noise may also increase the risk of sleep disturbances, stroke, diabetes, and becoming overweight. [2] Noise pollution is an environmental health concern since it is often a risk factor for developing other diseases like tinnitus or impaired speech discrimination. [32]

Psychological impacts of noise

Causal relationships have been discovered between noise and psychological effects such as annoyance, psychiatric disorders, and effects on psychosocial well-being. [5] Exposure to intense levels of noise can cause personality changes and violent reactions. [33] Noise has also been shown to be a factor attributed to violent reactions. [34] The psychological impacts of noise also include an addiction to loud music. This was researched in a study where non-professional musicians were found to have loudness addictions more often than non-musician control subjects. [35]

Psychological health effects from noise also include depression and anxiety. Individuals who have hearing loss, including noise induced hearing loss, may have their symptoms alleviated with the use of hearing aids. Individuals who do not seek treatment for their loss are 50% more likely to have depression than their aided peers. [36] These psychological effects can lead to detriments in physical care in the form of reduced self-care, work-tolerance, and increased isolation. [37]

Auditory stimuli can also serve as psychological triggers for individuals with post traumatic stress disorder (PTSD). [38]

Stress

Research commissioned by Rockwool, a multi-national insulation manufacturer headquartered in Denmark, reveals that in the UK one third (33%) of victims of domestic disturbances claim that loud parties have left them unable to sleep or made them stressed in the last two years. Around one in eleven (9%) [39] of those affected by domestic disturbances claims it has left them continually disturbed and stressed. More than 1.8 million people claim noisy neighbours have made their life a misery and they cannot enjoy their own homes. The impact of noise on health is potentially a significant problem across the UK given that more than 17.5 million Britons (38%) have been disturbed by the inhabitants of neighbouring properties in the last two years. For almost one in ten (7%) Britons this is a regular occurrence. [39]

The extent of the problem of noise pollution for public health is reinforced by figures collated by Rockwool from local authority responses to a Freedom of Information Act (FOI) request. This research reveals in the period April 2008 – 2009 UK councils received 315,838 complaints about noise pollution from private residences. This resulted in environmental health officers across the UK serving 8,069 noise abatement notices, or citations under the terms of the Anti-Social Behaviour (Scotland) Act. [39]

Westminster City Council [40] has received more complaints per head of population than any other district in the UK with 9,814 grievances about noise, which equates to 42.32 complaints per thousand residents. Eight of the top 10 councils ranked by complaints per 1,000 residents were in London.

Annoyance

Sudden impulse noises are typically perceived as more bothersome than noise from traffic of equal volume. [41] Annoyance effects of noise are minimally affected by demographics, but fear of the noise source and sensitivity to noise both strongly affect the 'annoyance' of a noise. [42] Sound levels as low as 40 dB(A) can generate noise complaints [43] and the lower threshold for noise producing sleep disturbance is 45 dB(A) or lower. [44]

Other factors that affect the annoyance level of sound include beliefs about noise prevention and the importance of the noise source, and annoyance at the cause (i.e., non-noise related factors) of the noise. [45] Many of the interpretations of the level of annoyance and the relationship between noise levels and resulting health symptoms could be influenced by the quality of interpersonal relationships at the workplace, as well as the stress level generated by the work itself. [5] [46] Evidence for impact on annoyance of long-term noise versus recent changes is uncertain. [45]

Approximately 35% to 40% of office workers find noise levels from 55 to 60 dB(A) extremely irritating. [5] The noise standard in Germany for mentally stressful tasks is set at 55 dB(A), [47] however, if the noise source is continuous, the threshold level for tolerability among office workers is lower than 55 dB(A). [5]

Child physical development

The U.S. Environmental Protection Agency authored a pamphlet in 1978 that suggested a correlation between low-birthweight (using the World Health Organization definition of less than 2,500 grams (88 oz)) and high sound levels, and also high rates of birth defects in places where expectant mothers are exposed to elevated sound levels, such as typical airport environments. Specific birth abnormalities included harelip, cleft palate, and defects in the spine. [48]

According to Lester W. Sontag of The Fels Research Institute (as presented in the same EPA study): "There is ample evidence that environment has a role in shaping the physique, behavior, and function of animals, including man, from conception and not merely from birth. The fetus is capable of perceiving sounds and responding to them by motor activity and cardiac rate change." The effects of noise exposure are highest when it occurs between 15 and 60 days after conception, a period in which major internal organs and the central nervous system are formed. [48]

Later developmental effects occur as vasoconstriction in the mother reduces blood flow and therefore oxygen and nutrition to the fetus. Low birth weights and noise were also associated with lower levels of certain hormones in the mother. These hormones are thought to affect fetal growth and to be good indicators of protein production. The difference between the hormone levels of pregnant mothers in noisy versus quiet areas increased as birth approached. [48]

In a 2000 publication, a review of studies on birthweight and noise exposure note that while some older studies suggest that when women are exposed to >65 dB aircraft noise, a small decrease in birthweight occurs, in a more recent study of 200 Taiwanese women including noise dosimetry measurements of individual noise exposure, the authors found no significant association between noise exposure and birth weight after adjusting for relevant confounders, e.g. social class, maternal weight gain during pregnancy, etc. [5]

Cognitive development

When young children are regularly exposed to levels of noise that interfere with speech, they may develop speech or reading difficulties, because auditory processing functions are compromised. Children continue to develop their speech perception abilities until they reach their teens. Evidence has shown that when children learn in noisier classrooms, they have more difficulties understanding speech than those who learn in quieter settings. [49]

In a study conducted by Cornell University in 1993, children exposed to noise in learning environments experienced trouble with word discrimination, as well as various cognitive developmental delays. [50] [51] In particular, the writing learning impairment dysgraphia is commonly associated with environmental stressors in the classroom. [52]

High noise levels have also been known to damage the physical health of small children. Children from noisy residences often have a heart rate that is significantly higher (by 2 beats/min on average) than those of children from quieter homes. [53]

Prevention

HPD fit testing Sistema proizvodstvennogo kontrolia effektivnosti SIZ organa slukha.jpg
HPD fit testing

A hearing protection device (HPD) is an ear protection device worn in or over the ears while exposed to hazardous noise to help prevent noise-induced hearing loss. HPDs reduce (not eliminate) the level of the noise entering the ear. HPDs can also protect against other effects of noise exposure such as tinnitus and hyperacusis. Proper hygiene and care of HPDs may reduce chances of outer ear infections. [55] There are many different types of HPDs available for use, including earmuffs, earplugs, electronic hearing protection devices, and semi-insert devices. [56] One can measure the personal attenuation rating through a hearing protection fit-testing system.

Earmuff style hearing protection devices are designed to fit over the outer ear, or pinna. Earmuff HPDs typically consist of two ear cups and a head band. [56] Earplug style hearing protection devices are designed to fit in the ear canal. Earplugs come in a variety of different subtypes. [56] Some HPDs reduce the sound reaching the eardrum through a combination of electronic and structural components. Electronic HPDs are available in both earmuff and custom earplug styles. Electronic microphones, circuitry, and receivers perform active noise reduction, also known as noise-cancelling, in which a signal that is 180-degrees out-of-phase of the noise is presented, which in theory cancels the noise. [56] Canal caps are similar to earplugs in that they consists of soft tip that is inserted into the opening of the ear canal. [56]

OSHA requires the use of hearing protection. But the HPD (without individual selection, training and fit testing) does not significantly reduce the risk of hearing loss. [57] For example, one study covered more than 19 thousand workers, some of whom usually used hearing protective devices, and some did not use them at all. There was no statistically significant difference in the risk of noise-induced hearing loss. [58]

Regulations

Environmental noise regulations usually specify a maximum outdoor noise level of 60 to 65 dB(A), while occupational safety organizations recommend that the maximum exposure to noise is 40 hours per week at 85 to 90 dB(A). For every additional 3 dB(A), the maximum exposure time is reduced by a factor 2, e.g. 20 hours per week at 88 dB(A). Sometimes, a factor of two per additional 5 dB(A) is used, however, these occupational regulations are acknowledged by the health literature as inadequate to protect against hearing loss and other health effects. In an effort to prevent noise-induced hearing loss, many programs and initiative have been created, like the Buy Quiet program, which encourages employers to purchase quieter tools and equipment, and the Safe-In-Sound Award, which recognizes organizations with successful hearing loss prevention strategies. [59] [60]

With regard to indoor noise pollution in residences, the U.S. Environmental Protection Agency (EPA) has not set any restrictions on limits to the level of noise. Rather, it has provided a list of recommended levels in its Model Community Noise Control Ordinance, which was published in 1975. For instance, the recommended noise level for indoor residences is less than or equal to 45 dB. [61] [62]

Noise pollution control in residences is not funded by the federal government in part because of the disagreements in establishing causal links between sounds and health risks, since the effect of noise is often psychological and also, because it leaves no singular tangible trace of damage on the human body. For instance, hearing loss could be attributed to a variety of factors including age, rather than solely due to excessive exposure to noise. [63] [64] A state or local government is able to regulate indoor residential noise, however, such as when excessive noise from within a home causes disturbances to nearby residences. [63] [65]

Effects on dogs

While people are often educated on the effects of noise exposure in humans, there are also different noise exposure effects in animals as well. An example of this would be in dogs, and the noise exposure levels occurring within kennels. Dogs experience this noise exposure whether it be a long stay at an animal shelter, or a weekend stay at a boarding facility.

Organizations like NIOSH and OSHA have different regulations when it comes to the noise exposure levels in industrial workers. Currently there are no regulations related to the noise exposure for dogs even with such damaging effects related to their health. Health risks dogs are exposed to include ear damage and behavioral changes.

The average noise exposure in a kennel is greater than 100 dB SPL. According to OSHA these levels would yield in the use of hearing protection for the workers of those kennels due to the risk of noise induced hearing loss. The anatomical structures of the human and dog ears are very similar, so it is thought that these levels will negatively impact the hearing of canines in kennels. The ABR can be used to estimate the hearing threshold of dogs, and can be used to show either a temporary threshold shift or permanent threshold shift after being exposed to excessive sound levels. [66]

Behavioral effects to excessive noise exposure include hiding, urinating, defecating, panting, pacing, drooling, disregard to commands, trembling, and barking. [67] These behavioral patterns pose a much greater problem to canines than meets the eye. All of these behavioral patterns are characteristics that result in a longer stay at the kennels before being adopted. [68] A longer stay at the shelter results in a longer duration of noise exposure and therefore more likely to show either a temporary or permanent threshold shift in the canine's hearing. [66]

These excessive noise levels are not only harming the dogs physical and psychological state, but the workers' and potential adoptive families' physical and psychological state as well. The workers' psychological state could affect the care provided to the dogs. These loud noise exposures also have the potential to reduce the amount of time that potential adoptive families spend in the facility. This can result in less dogs being adopted and more time being exposed to excessive sound levels. [69]

To reduce the level of noise exposure poses a little more difficulty because the majority of the noise is coming from the dogs (barking), but structural changes can be made to the facilities in order to reduce the noise. Structural changes could include how many dogs are put in one area, more absorbing material rather than metal cages and cement walls and floors, and possibly in the future use of hearing protection devices (HPD) for the dogs. All of these structural changes would also benefit the humans involved as well as the use of HPD's (ear plugs).

See also

Related Research Articles

<span class="mw-page-title-main">Noise</span> Unwanted sound

Noise is unwanted or harmful sound considered unpleasant, loud, or disruptive to hearing. From a physics standpoint, there is no distinction between noise and desired sound, as both are vibrations through a medium, such as air or water. The difference arises when the brain receives and perceives a sound.

<span class="mw-page-title-main">Hearing loss</span> Partial or total inability to hear

Hearing loss is a partial or total inability to hear. Hearing loss may be present at birth or acquired at any time afterwards. Hearing loss may occur in one or both ears. In children, hearing problems can affect the ability to acquire spoken language, and in adults it can create difficulties with social interaction and at work. Hearing loss can be temporary or permanent. Hearing loss related to age usually affects both ears and is due to cochlear hair cell loss. In some people, particularly older people, hearing loss can result in loneliness.

<span class="mw-page-title-main">Noise pollution</span> Excessive, displeasing environmental noise

Noise pollution, or sound pollution, is the propagation of noise or sound with ranging impacts on the activity of human or animal life, most of which are harmful to a degree. The source of outdoor noise worldwide is mainly caused by machines, transport and propagation systems. Poor urban planning may give rise to noise disintegration or pollution, side-by-side industrial and residential buildings can result in noise pollution in the residential areas. Some of the main sources of noise in residential areas include loud music, transportation, lawn care maintenance, construction, electrical generators, wind turbines, explosions and people.

Tinnitus is a variety of sound that is heard when no corresponding external sound is present. Nearly everyone experiences faint "normal tinnitus" in a completely quiet room; but it is of concern only if it is bothersome, interferes with normal hearing, or is associated with other problems. The word tinnitus comes from the Latin tinnire, "to ring". In some people, it interferes with concentration, and can be associated with anxiety and depression.

<span class="mw-page-title-main">Environmental noise</span>

Environmental noise is an accumulation of noise pollution that occurs outside. This noise can be caused by transport, industrial, and recreational activities.

<span class="mw-page-title-main">Aircraft noise pollution</span> Noise generated by powered aircraft

Aircraft noise pollution refers to noise produced by aircraft in flight that has been associated with several negative stress-mediated health effects, from sleep disorders to cardiovascular disorders. Governments have enacted extensive controls that apply to aircraft designers, manufacturers, and operators, resulting in improved procedures and cuts in pollution.

Ototoxicity is the property of being toxic to the ear (oto-), specifically the cochlea or auditory nerve and sometimes the vestibular system, for example, as a side effect of a drug. The effects of ototoxicity can be reversible and temporary, or irreversible and permanent. It has been recognized since the 19th century. There are many well-known ototoxic drugs used in clinical situations, and they are prescribed, despite the risk of hearing disorders, for very serious health conditions. Ototoxic drugs include antibiotics, loop diuretics, and platinum-based chemotherapy agents. A number of nonsteroidal anti-inflammatory drugs (NSAIDS) have also been shown to be ototoxic. This can result in sensorineural hearing loss, dysequilibrium, or both. Some environmental and occupational chemicals have also been shown to affect the auditory system and interact with noise.

<span class="mw-page-title-main">Earplug</span> Device to protect ears from loud noises

An earplug is a device that is inserted in the ear canal to protect the user's ears from loud noises, intrusion of water, foreign bodies, dust or excessive wind. Since they reduce the sound volume, earplugs may prevent hearing loss and tinnitus, in some cases.

<span class="mw-page-title-main">Earmuffs</span> Ear-protecting headgear worn over ears to protect from cold or loud noise

Earmuffs are clothing accessories or personal protective equipment designed to cover a person's ears for hearing protection or warmth. They consist of a thermoplastic or metal head-band that fits over the top or back of the head, and a cushion or cup at each end to cover the ears.

<span class="mw-page-title-main">Sensorineural hearing loss</span> Hearing loss caused by an inner ear or vestibulocochlear nerve defect

Sensorineural hearing loss (SNHL) is a type of hearing loss in which the root cause lies in the inner ear, sensory organ, or the vestibulocochlear nerve. SNHL accounts for about 90% of reported hearing loss. SNHL is usually permanent and can be mild, moderate, severe, profound, or total. Various other descriptors can be used depending on the shape of the audiogram, such as high frequency, low frequency, U-shaped, notched, peaked, or flat.

Hyperacusis is an increased sensitivity to sound and a low tolerance for environmental noise. Definitions of hyperacusis can vary significantly, but it is often categorized into four subtypes: loudness, pain, annoyance, and fear. It can be a highly debilitating hearing disorder.

In acoustics, noise measurement can be for the purpose of measuring environmental noise or measuring noise in the workplace. Applications include monitoring of construction sites, aircraft noise, road traffic noise, entertainment venues and neighborhood noise. One of the definitions of noise covers all "unwanted sounds". When sound levels reach a high enough intensity, the sound, whether it is wanted or unwanted, may be damaging to hearing. Environmental noise monitoring is the measurement of noise in an outdoor environment caused by transport, industry and recreational activities. The laws and limits governing environmental noise monitoring differ from country to country.

<span class="mw-page-title-main">Noise-induced hearing loss</span> Medical condition

Noise-induced hearing loss (NIHL) is a hearing impairment resulting from exposure to loud sound. People may have a loss of perception of a narrow range of frequencies or impaired perception of sound including sensitivity to sound or ringing in the ears. When exposure to hazards such as noise occur at work and is associated with hearing loss, it is referred to as occupational hearing loss.

<span class="mw-page-title-main">Hearing conservation program</span>

Hearing conservation programs are designed to prevent hearing loss due to noise. Hearing conservation programs require knowledge about risk factors such as noise and ototoxicity, hearing, hearing loss, protective measures to prevent hearing loss at home, in school, at work, in the military and, and at social/recreational events, and legislative requirements. Regarding occupational exposures to noise, a hearing conservation program is required by the Occupational Safety and Health Administration (OSHA) "whenever employee noise exposures equal or exceed an 8-hour time-weighted average sound level (TWA) of 85 decibels (dB) measured on the A scale or, equivalently, a dose of fifty percent." This 8-hour time-weighted average is known as an exposure action value. While the Mine Safety and Health Administration (MSHA) also requires a hearing conservation program, MSHA does not require a written hearing conservation program. MSHA's hearing conservation program requirement can be found in 30 CFR § 62.150, and is very similar to the OSHA hearing conservation program requirements. Therefore, only the OSHA standard 29 CFR 1910.95 will be discussed in detail.

<span class="mw-page-title-main">Occupational hearing loss</span> Form of hearing loss

Occupational hearing loss (OHL) is hearing loss that occurs as a result of occupational hazards, such as excessive noise and ototoxic chemicals. Noise is a common workplace hazard, and recognized as the risk factor for noise-induced hearing loss and tinnitus but it is not the only risk factor that can result in a work-related hearing loss. Also, noise-induced hearing loss can result from exposures that are not restricted to the occupational setting.

Musicians can experience a number of health problems related to the practice and performance of music. The differences in career paths, occupations and performance scenarios are some of the determinants of a wide range of possible health effects.

<span class="mw-page-title-main">Hearing protection device</span> Protection device for auditory organs

A hearing protection device, also known as a HPD, is an ear protection device worn in or over the ears while exposed to hazardous noise and provide hearing protection to help prevent noise-induced hearing loss. HPDs reduce the level of the noise entering the ear. HPDs can also protect against other effects of noise exposure such as tinnitus and hyperacusis. There are many different types of HPDs available for use, including earmuffs, earplugs, electronic hearing protection devices, and semi-insert devices.

<span class="mw-page-title-main">Hearing protection fit-testing</span> Test for determining the effectiveness hearing protection devices

Hearing protector fit-testing is a method that measures the degree of noise reduction obtained from an individual wearing a particular hearing protection device (HPD) - for example, a noise canceling earplug or earmuff. Fit testing is necessary due to the fact that noise attenuation varies across individuals. It is important to note that attenuation can sometimes score as zero due to anatomical differences and inadequate training, as to the proper wear and use. Labeled HPD attenuation values are average values that cannot predict noise attenuation for an individual; in addition, they are based on laboratory measurements which may overestimate the noise reduction obtained in the real world.

Causes of hearing loss include ageing, genetics, perinatal problems, loud sounds, and diseases. For some kinds of hearing loss the cause may be classified as of unknown cause.

<span class="mw-page-title-main">Safe listening</span> Avoiding hearing damage from intentionally heard sounds

Safe listening is a framework for health promotion actions to ensure that sound-related recreational activities do not pose a risk to hearing.

References

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