Gender Differences in the Prevalence of Vocal Symptoms in Smokers  Finland Susanna Simberg, Hanna Udd, and Pekka Santtila, Abo,

Summary: Objectives. The purpose of the present study was to explore possible gender differences in the occurrence of vocal symptoms in smokers. Methods. A total of 1728 respondents, 68% women and 32% men completed a ‘‘Speech, language and voice’’ questionnaire. The questions concerning six vocal symptoms along with questions concerning smoking habits were used as the main data source for the present study. Results. About 24% of the men and 22% of the women were smokers. Male smokers did not differ from male nonsmokers in reporting vocal symptoms. In contrast, female smokers were more likely than female nonsmokers to report having vocal symptoms. Smoking seemed to have a significant effect on four of the six vocal symptoms in the female smokers. Conclusions. There appears to be a difference in the effects of smoking between men and women. The female vocal folds may be more vulnerable to cigarette smoke, probably due to anatomical and physiological differences. Nevertheless, it is yet to be demonstrated that the vocal symptoms in female smokers are causally related to smoking. It could be meaningful to use gender specific strategies when informing smokers about the risks for voice problems. Key Words: Vocal symptoms–Smoking–Gender differences. INTRODUCTION Smoking has generally been seen as a primary cause for voice disorders. It is well documented that smoking adversely affects the epithelium of the vocal folds1–5 and causes several kinds of lesions in the airways (for a review, see Dye and Adler).6 It is also a central factor in the etiology of laryngeal cancer7 and Reinke’s edema.8,9 Smoking causes increased irregularity in the vibration of the vocal folds in otherwise healthy persons.1,2,10–12 The results of several studies show that smoking strongly affects fundamental frequency (F0) with lowered values in smokers.2,11–15 Awan and Morrow1 studied young female smokers and nonsmokers and the results showed that the smokers had edema and erythema on their vocal folds even if they probably had been smoking a relatively short time since their mean age was about 20 years. These female smokers also had significantly more abnormal laryngeal color and an increased glottal gap size compared with the nonsmokers. The results of a study by Awan and Alphonso16 showed that young female smokers also had reduced vital capacity and lowered maximum phonation time compared with nonsmokers. These results indicate that smoking even for a short time might have a negative effect on the voice. In general, women seem to have more voice problems than men.17–20 Some studies have explored possible differences in the voices of female and male smokers. Sorensen and Horii15 studied changes in F0 in 40 smokers and 40 nonsmokers, mean age 35–40 years. When making comparisons between the female and male participants, the results showed that F0 was significantly lower in male smokers compared with nonAccepted for publication November 25, 2014. From the Department of Psychology and Logopedics,  Abo Akademi University, Fabriksgatan 2, 20500  Abo, Finland. Address correspondence and reprint requests to Susanna Simberg, Department of Psychology and Logopedics,  Abo Akademi University, Fabriksgatan 2, 20500  Abo, Finland. E-mail: [email protected] Journal of Voice, Vol. 29, No. 5, pp. 588-591 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.11.010

smokers, although there was no significant difference between female smokers and nonsmokers. Gonzales and Carpi11 compared the voices of 91 smokers and 68 nonsmokers, mean age about 22 years. The results of their study showed that F0 parameters were affected by smoking, especially in women, with lower values for smokers compared to nonsmokers. The difference was significant for women but not for men.11 The diverse results from the two studies might be due to methodological differences and differences in the age of the participants. Also, the groups were quite small in both studies, which may have increased the likelihood of chance effects. Although the detrimental effects of smoking on voice are well known, it still is common. The results of several studies show that also persons working in voice demanding occupations are reported to smoke.20–24 Smoking seems to be usual also in those studying for such occupations.19,25–27 The results of some studies show that smokers do not perceive voice changes1,10 and that there does not seem to be any correlation between frequency of vocal symptoms and smoking.28,29 In three studies involving large population groups, smokers have even reported less voice problems than nonsmokers.20,29,30 The results of these studies seem to indicate that smokers do not experience vocal symptoms or that they understate them. The purpose of the present study was to explore possible gender differences in the occurrence of vocal symptoms in smokers. METHODS Participants A total of 1728 twins, 68% women and 32% men, born between 1961 and 1989, completed a ‘‘Speech, language and voice’’ questionnaire. The participants, 254 twin pairs and 1220 single twins, were part of a twin cohort including twins born between 1961 and 1989 contacted for an unrelated study on sexual behavior followed by a questionnaire on voice.31 The questionnaire from which the measures analyzed in the present study derive was

Susanna Simberg, et al

TABLE 1. Number of Frequently Occurring Vocal Symptoms Occurring During the Past Year in Male Smokers and Nonsmokers (n ¼ 479)

Smoking habits Regular smokers Nonsmokers

589

Gender Differences and Vocal Symptoms in Smokers

No symptoms

One symptom

Two symptoms or more

n

%

n

%

n

%

88

77.2

9

7.9

17

14.9

257

70.4

60

16.4

48

13.2

originally designed for a study on genetics and voice,32 mainly by the first author of the present study The questionnaires for both the unrelated study and the study on genetics and voice were distributed by the Centre of Excellence for Behavior Genetics at  Abo Akademi University. The questionnaire was selfexplanatory and it is possible that the term occasional smoker could have been understood in various ways. Therefore, the results for only regular smokers (n ¼ 334) and nonsmokers (n ¼ 1168) will be reported here. Questionnaire In all, the questionnaire consisted of 60 questions concerning speech, language, and voice. The questionnaire also included health-related question and questions about occupation. The questions concerning vocal symptoms along with questions concerning smoking habits were used as the main data source for the present study. The six vocal symptoms presented were The voice get strained or tires, The voice gets low or hoarse, Throat clearing or coughing while talking, Voice breaks while talking, A sensation of tension or lump in throat, and Difficulty in being heard. These questions have been used in several earlier studies on various populations.19,32–35 The participants were requested to report how frequently they had experienced each symptom during the past year by selecting one of the four alternatives: daily, weekly, more seldom, and never. The participants were requested to answer if they smoked and if so, how frequently they did that. The alternatives for responding were regular smoker, occasional smoker, or nonsmoker.

Data analyses The number of frequently occurring symptoms in male and female smokers and nonsmokers was explored. Frequently occurring symptoms were defined as symptoms experienced every week or every day during the past year. The reports of the number of frequently occurring vocal symptoms in smokers and nonsmokers and the individual symptoms during the past year and possible gender differences were calculated. Male smokers and nonsmokers were compared regarding prevalence of vocal symptoms. The same comparisons were performed on the female participants. IBM SPSS Statistics 20 (Armonk, NY) was used for the statistical analyses. Since the data were on a nominal level, the nonparametric Chisquare test was chosen. The significance level was set to P < 0.05.

RESULTS In this study, 23.8% of the men and 21.5% of the women were smokers. The difference in smoking habits between men and women was not significant. This is in line with the smoking habits in Finland according to a large population-based survey study. In 2006, when the data for the present study were gathered, 24% of men and 19% of women in Finland were smokers.36 Next, we analyzed the possible effects of smoking on vocal symptoms separately for the male and female participants. The results showed no significant differences in the number of frequently occurring symptoms in the different smoking groups among the male participants (Table 1). Additionally, the smoking habits did not seem to have significant effects on any of the individual vocal symptoms occurring during the past year among the male participants (Table 2). Women who smoked reported significantly more frequently occurring symptoms during the past year than female nonsmokers (Table 3). As to the individual symptoms, there were significant differences among the female smokers and nonsmokers with the smokers reporting more of the symptoms The voice becomes low or hoarse, The voice gets strained or tires, Voice breaks while talking, and Throat clearing or coughing while talking (Table 4). For the other two symptoms, the differences were not significant.

TABLE 2. The Occurrence of Individual Vocal Symptoms (%) During the Past Year in Male Smokers and Nonsmokers (n ¼ 477–479) Vocal symptoms The voice gets strained or tires The voice gets low or hoarse Voice breaks while talking Difficulty in being heard Throat clearing or coughing while talking A sensation of muscle tension or lump in the throat Note. n.s.= not significant.

Regular smoker

Nonsmoker

c2

P

2.6 7.9 2.6 8.0 18.4 9.6

4.7 5.8 5.0 9.1 22.2 9.6

0.89 0.68 1.12 0.13 0.74 0.00

n.s. n.s. n.s. n.s. n.s. n.s.

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Journal of Voice, Vol. 29, No. 5, 2015

TABLE 3. Number of Frequently Occurring Vocal Symptoms Occurring During the Past Year in Female Smokers and Nonsmokers (n ¼ 1022)

Smoking habits Regular smokers Nonsmokers

No symptoms

One symptom

Two symptoms or more

n

%

n

%

n

%

106

48.2

49

22.3

65

29.5

531

66.2

109

13.6

162

20.2

c2 (2) ¼ 24.208, P < 0.001.

DISCUSSION The purpose of the present study was to explore possible gender differences in the prevalence of vocal symptoms in smokers in a large unselected sample from the population. The etiology for voice problems is multifactorial and it is not possible to prove a causal relationship between smoking and vocal symptoms using a survey methodology. In this study, frequently occurring symptoms, that is, symptoms occurring every week or every day during the past year were enquired. Symptoms that occur that often can be seen as chronic, which imply that smoking is one factor contributing to them. The causality between smoking and vocal symptoms could in the future be explored using a twin study design. However, in this study, the number of twin pairs was too low to employ the discrepant MZ-twin design, which allows firmer causal conclusions. Most likely, former smokers categorized themselves as nonsmokers. It is possible that some participants had quitted smoking recently, which might have some impact on the results since some vocal symptoms might persist. We found that smoking might be associated with vocal symptoms in women but not in men. For men, smoking did not seem to have any effect on the prevalence of vocal symptoms. There was neither any significant difference between smokers and nonsmokers in the number of frequently occurring symptoms nor in the prevalence of the specific symptoms. Still, F0 has been found to be lower in male smokers than in nonsmokers.15

As we relied on self-reports in the present study, it may be that men do not experience a lower or hoarse voice as a symptom with the same likelihood as women do. Another reason for not recognizing a symptom like hoarseness might be that persons adapt to a hoarse voice quality or merely see them as a personal characteristic.37 The main finding of the study was that there was a significant difference in the number of frequently occurring symptoms in female smokers compared with nonsmokers. Smoking possibly had a significant effect on four of the six specific vocal symptoms in the female smokers. In contrast to men, women might be more likely to recognize vocal symptoms such as The voice becomes low or hoarse than men.11 Females’ F0 is higher than male’s and they may therefore be more sensitive to changes in their F0. However, the female smokers also reported the symptoms The voice gets strained or tires, Voice breaks while talking, and Throat clearing or coughing while talking occurring more often than female nonsmokers, which could indicate that the female vocal folds are more vulnerable to cigarette smoke. The results of a study on the effect of smoking on the Dysphonia Severity Index (DSI) in women with perceptually normal voices showed that there were significant differences in the DSI scores between smokers and nonsmokers, suggesting early changes in vocal function secondary to smoking.13 Our results indicate that there is a difference in the prevalence of vocal symptoms in male and female smokers. Women are reported to have a tendency to report more symptoms in general.38 Still, the adverse effects of smoking on the respiratory tract have generally been found to be bigger in female than in male smokers.39–42 This might also affect voice production and be an explanation to the gender differences found here. Additionally, it is likely that smoking affects women’s voices more than men’s voices because of structural differences in the laryngeal anatomy between women and men. A review by Hunter et al38 on gender differences affecting vocal health addresses several aspects. Women have shorter and thinner vocal folds, which vibrate with a higher frequency than men’s vocal folds, which makes the vocal folds of women more exposed to vibratory force. Women also have less collagen and hyaluronic their vocal folds.40 Collagen and hyaluronic acid are important in the healing process of wounds.8,43 This indicates that the wound healing process in the vocal folds in women is

TABLE 4. The Occurrence of Individual Vocal Symptoms (%) During the Past Year in Female Smokers and Nonsmokers (n ¼ 1013– 1022) Symptom (%) The voice gets strained or tires The voice gets low or hoarse Voice breaks while talking Difficulty in being heard Throat clearing or coughing while talking A sensation of muscle tension or lump in the throat Note. n.s.= not significant.

Regular smoker

Nonsmoker

c2

P

20.2 23.2 11.9 11.9 40.3 18.9

12.3 12.7 7.4 10.0 23.3 15.5

8.74 14.85 4.60 0.64 24.99 1.49

0.003 0.001 0.032 n.s. 0.001 n.s.

Susanna Simberg, et al

Gender Differences and Vocal Symptoms in Smokers

less effective than in men and that female smokers therefore might be more likely to suffer from pathological changes due to smoking and experience more vocal symptoms. It is possible that at least male smokers understate their voice problems. As suggested by Van Houtte et al,30 it is also possible that smokers in general cannot distinguish voice-related problems from those that might be related to smoking. It is of outmost importance to motivate voice patients to quit smoking. Since smokers might be ignorant of vocal symptoms or underestimate, one motivating factor might be to make them see the connection between symptoms and smoking habits. It could be meaningful to use genderspecific strategies when informing smokers about the risks for voice problems. REFERENCES 1. Awan SN, Morrow D. Videostroboskopic characteristics of young adult female smokers vs. nonsmokers. J Voice. 2007;21:211–223. 2. Guimaraes I, Abberton E. Health and voice quality in smokers: an exploratory investigation. Logoped Phoniatr Vocol. 2005;30:185–191. 3. Hirabayashi H, Koshii K, Uno K, et al. Laryngeal epithelial changes on effects of smoking and drinking. Auris Nasus Larynx. 1990;17:105–114. 4. Martins RH, Goncalves TM, Madeira SL, Dias NH, de Oliveira Semenzati G. Scanning electron microscopy of the tongue, pharynx, and larynx of rats exposed to cigarette smoke. J Voice. 2014;28:287–290. 5. M€ uller K-M, Krohn B. Smoking habits and their relationship to precancerous lesions of the larynx. J Cancer Res Clin Oncol. 1980;96:211–217. 6. Dye JA, Adler KB. Effects of cigarette smoke on epithelial cells of the respiratory tract. Thorax. 1980;49:825–834. 7. Auerbach O, Hammond EC, Garfinkel L. Histologic changes in the larynx in relation to smoking habits. Cancer. 1970;25:92–104. 8. Branski RC, Verdolini K, Sandulache V, Rosen CA, Hebda PA. Vocal fold wound healing: a review for clinicians. J Voice. 2006;20:432–442. 9. Marcotullio D, Magliulio G, Pezone T. Reinke’s edema and risk factors: clinical and histopatologic aspects. Am J Otolaryngol. 2002;23:81–84. 10. Chai L, Sprecher AJ, Zhang Y, Liang Y, Chen H, Jiang JJ. 2011 Perturbation and nonlinear dynamic analysis of adult male smokers. J Voice. 2011;25: 342–347. 11. Gonzales J, Carpi A. Early effects of smoking on the voice: a multidimensional study. Med Sci Monit. 2004;10:649–656. 12. Vincent I, Gilbert HR. The effects of cigarette smoking on the female voice. Logoped Phoniatr Vocol. 2012;37:22–32. 13. Awan SN. The effect of smoking on the dysphonia severity index in females. Folia Phoniatr Logop. 2011;63:65–71. 14. Gilbert H, Weismer G. The effects of smoking on the speaking fundamental frequency of adult women. J Psycholinguist Res. 1974;3:225–231. 15. Sorensen D, Hoirii Y. Cigarette smoking and voice fundamental frequency. J Commun Disord. 1982;15:135–144. 16. Awan S, Alphonso V. Effects of smoking on respiratory capacity and control. Clin Linguist Phon. 2007;21:626–636. 17. Coyle SM, Weinrich BD, Stemple JC. Shifts in relative prevalence of laryngeal pathology in a treatment-seeking population. J Voice. 2001;15: 424–440. 18. Fritzell B. Voice disorders and occupations. Logoped Phoniatr Vocol. 1996; 21:7–11. 19. Ohlsson A-C, Eva M Andersson EM, S€odersten M, Simberg S, Barreg ard L. Prevalence of voice symptoms and risk factors in teacher students. J Voice. 2012;26:629–634. 20. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. J Speech Lang Hear Res. 2004;47:281–293.

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Gender Differences in the Prevalence of Vocal Symptoms in Smokers.

The purpose of the present study was to explore possible gender differences in the occurrence of vocal symptoms in smokers...
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