Risk of sound-induced hearing loss from exposure to video gaming or esports: a systematic scoping review

Introduction

The World Health Organisation (WHO) recognises voluntary recreational exposure to high-intensity sounds, known as unsafe listening, as an important modifiable risk factor of hearing loss.1–3 The burden of unsafe listening is high and can occur via exposure to several sources of high-intensity sounds, such as personal listening devices and entertainment venues.2–4 Another potential source of unsafe listening that has received less attention is video gaming, including electronic sports (known as esports).3 Gaming may be a source of unsafe listening because individuals often play video games at high-intensity sound levels and for several hours at a time. Furthermore, gaming is one of the most popular leisure activities worldwide, with an online source estimating there were over 3 billion gamers worldwide in 2022.5 Identifying common sources of unsafe listening is important because it is possible to reduce unsafe listening practices through known public health practices and by developing and implementing global policies focused on promotion of safe listening practices.6

Research suggests that recurring, or even a single, exposure to high-intensity sounds, could permanently damage the auditory system, commonly referred to as sound-induced or noise-induced hearing loss.7–9 Early signs of sound-induced hearing loss include (1) transient or permanent tinnitus, which can be defined as a perceived sensation, often ringing or buzzing, in the absence of an external stimulus, (2) hyperacusis, which can be defined as enhanced sensitivity to sound, and/or (3) difficulties understanding speech, particularly when background noise is present.1 10 Exposure to high-intensity sounds has been tied to 'hidden hearing loss,’ which exists without measurable permanent changes to audiometric thresholds but can present as the symptoms described above.11 12 It has been hypothesised that hidden hearing loss is common among young people given that many young people engage in unsafe listening practices.4 12 Importantly, exposure to high-intensity sounds among young people might also make them more vulnerable to developing age-related hearing loss later in life.13 14 It is important to note that permanent hearing loss and/or tinnitus caused by high-intensity sounds can be prevented. Identifying modifiable risk factors of hearing loss and/or tinnitus, such as unsafe listening, can promote its prevention, thus reducing the burden of these conditions on individuals and society.

There are several ways in which unsafe listening may occur when playing video games. First, individuals can play video games at home through a gaming console, personal computer (PC) or on a smart device (eg, smart phone or tablet). Second, video games can be played over local area networks in gaming centres or PC rooms, which are locations that offer computers or gaming consoles primarily for the purpose of playing multiplayer games. Headphones are frequently used, and individuals may increase the volume to higher levels than their preferred listening levels to overcome the background noise that is common in these settings. While gaming centres and PC rooms exist worldwide, the vast majority are in China and other Asian countries. Third, electronic sports, termed esports, involve competitive, organised gaming and are rapidly growing in popularity. Some esports players are professional gamers, and therefore may practice for many hours a day, often using headphones, and compete regularly in online or in-person competitions or tournaments. Esports competitions or tournaments can be available to spectators either online or in-person at esports arenas. These esports arenas livestream virtual esports events, and some also host esports competitors in person during which spectators watch the competitions. Therefore, both esports gamers and spectators may be at risk for unsafe listening.

Permissible levels of recreational sound exposure can be estimated from equivalent occupational noise exposure limits, which are defined as an average sound intensity (eg, 80 decibels (dB)) over a period of time—for example, a 40-hour working week).7 15 Permissible noise exposure limits vary slightly by region or by regulatory agencies or organisations and the target population’s age.7 16 17 Here, we focus on noise exposure limits published by the International Telecommunication Union (ITU) in collaboration with WHO.7 Sound intensity (dB) is measured on a logarithmic scale and there is a time–intensity trade-off, known as an exchange rate, for permissible levels and duration of exposure, and therefore, permissible levels of noise exposure change drastically by sound level. For example, based on a permissible noise exposure level of 80 dB for 40 hours a week with a 3 dB exchange rate, the permissible exposure time of an 83 dB sound is 20 hours, of an 86 dB sound is 10 hours, of a 92 dB sound is 2.5 hours and of a 98 dB sound is 38 min per week.7 15 18 For children, permissible noise exposure levels are lower and can be based on a permissible noise exposure level of 75 dB for 40 hours a week. Under this definition, children can safely listen to sound at an 83 dB sound for approximately 6.5 hours, an 86 dB sound for approximately 3.25 hours, a 92 dB sound for 45 min, and a 98 dB sound for only 12 min per week.7

Using an average sound intensity to define permissible levels of sound exposure is common; however, an average does not define whether impulse sounds, which can be defined as sound consisting of bursts lasting less than one second and with peak levels at least 15 dB higher than the background sound, are included in the average.19 In occupational settings, impulse noise may have negative effects on hearing, beyond what can be explained by exposure to non-impulse noise, and may lead to acute acoustical trauma.19 20 In general, the audio of video games comprises of (1) sounds of similar intensities, and (2) often (particularly in shooter games), impulse sounds. Permissible exposure limits for impulse sounds vary but are approximately 100 dB for children and 130–140 dB for adults.17 19

Taken together, it is plausible that gaming may be a source of unsafe listening. Yet, it is not known whether gaming may pose a risk to auditory function. Efforts towards prevention of global hearing loss would benefit from identifying sources of unsafe listening, which may include gaming. Therefore, the objective of this systematic scoping review is to synthesise current evidence related to relationships between gaming and the potential risk of hearing loss and/or tinnitus.

Methods

This systematic scoping review was conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews (PRISMA-ScR).21 The protocol was registered with Open Science Framework (registration: https://doi.org/10.17605/OSF.IO/T397A). Given the nature of this review, a critical appraisal of individual sources of evidence was not conducted.

Results

The results section is organised as follows. First, we present information from peer-reviewed articles focusing on relationships between gaming and hearing and/or tinnitus, which comprise the main findings from this review. Second, we present information from peer-reviewed articles and grey literature sources that mention, but do not focus on, relationships between gaming and hearing and/or tinnitus. Third, we present additional information from grey literature sources.

A total of 63 non-duplicate peer-reviewed citations were identified that focused on relationships between gaming and hearing and/ or tinnitus. After the final review, 14 peer-reviewed articles were included in this study. The study selection process is shown in figure 1.22 Studies were from nine countries, corresponding to representation from American (n = 2), European (n = 4), South-East Asian (n = 6) and Western Pacific (n = 2) regions. Twelve studies were published in English, one was published in Korean and translated to English for review, and one was published in Chinese.

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Discussion

The limited available evidence collated in this systematic scoping review indicates that gaming may be a source of unsafe listening. Therefore, gamers who are listening at high-intensity sound levels and for long periods of time may be at risk of permanent sound-induced hearing loss and/or tinnitus. Findings from this study highlight the need for additional research focused on the risk of hearing loss and/or tinnitus from gaming. Furthermore, findings suggest that there may be a need to prioritise interventions, such as initiatives focused on education and awareness of the potential risks of gaming, that can help promote safe listening among gamers.

Only two studies published in the last 10 years objectively measured average sound levels from video games or at gaming centres and reported high sound levels at approximately 84.6 to 91.2 dB(A) and 87.7 dB(A), respectively.31 34 Furthermore, three studies reported that individuals spend an average of 3 hours per week playing video games.25 26 31 Based on WHO permissible noise exposure levels described earlier (exposure level 75 dB, 40 hours per week, 3 dB exchange rate), the maximum number of hours per week a young person can safely listen at 83 dB, 86 dB and 92 dB is 6.5 hours, 3.25 hours and 45 min, respectively. For adults (exposure level 80 dB, 40 hours per week, 3 dB exchange rate) the maximum hours a week an individual can safely listen at those sound levels increases to 20 hours, 10 hours and 2.5 hours, respectively. As mentioned earlier, impulse sounds are also common in gaming and the presence of impulse noise is not necessarily captured by average sound intensity levels. One study reported that impulse sounds reached levels as high as 119 dB(C) during game play.34 This is important because impulse sounds may have additional negative impacts on hearing.19 Although the data provided in this review are limited, they suggest that some gamers, particularly those who play frequently, and at or above the average sound levels described by papers included in this review, probably exceed permissible sound exposure limits, and are thus engaging in unsafe listening practices, which could put them at risk for developing permanent hearing loss and/or tinnitus.7 Importantly, no studies in this review focused on esports, either for the individual esports gamer, or for esports spectators, as a potential source of unsafe listening, which highlights an important gap in the scientific literature. Given that esports are rapidly growing in popularity, research to understand the potential impacts of esports gaming on hearing, for both players and spectators, is warranted.

The prevalence of gaming and thus, the population who may be at risk of hearing loss and/or tinnitus from unsafe listening, probably varies by demographic factors, such as region, sex and age. An online source suggests that video game revenues are highest in Asia Pacific and North America, although video games are played worldwide, and that most gamers are under 18 (24%) or between 18 and 34 (36%) years of age.5 Along these lines, seven of the 14 studies in this review were conducted in Asia (South Korea, Indonesia, Japan, China), whereas the others were conducted in Australia, Europe and North America. While no studies in this review evaluated sex differences in associations between gaming and hearing or tinnitus, study results indicated that males play video games more frequently, for longer periods of time, and at higher-intensity sound levels.25 26 30 Of the cohort studies included in this review, all but one included children or young people in their samples. This is consistent with the source mentioned above that indicates the prevalence of gaming is probably highest in children and young adults. There may be other demographic factors not described in the studies included in this review, such as socioeconomic position, which might also be associated with unsafe listening practices among gamers.67 Future research is needed to identify populations at high risk of unsafe listening during gaming, which could inform targeted intervention strategies to prevent hearing loss and/or tinnitus among gamers.

Several studies included in this review reported associations or correlations of gaming with hearing loss and/or tinnitus, yet these relationships were detected only for certain outcomes such as high-frequency, but not speech-frequency, hearing thresholds, and one study did not report an association of gaming with hearing thresholds.23 27 28 31 33 Furthermore, some studies have reported inconsistent associations of other sources of leisure sound exposure, such as use of personal listening devices, with permanent changes to hearing.68–71 These inconsistent results may be due, in part, to differences in study methodology, such as study sample composition and/or definitions of gaming-related and hearing-related measures (eg, self-reported vs audiometric). It is likely that the type of gaming and the setting in which it occurs (ie, in gaming centres, on PCs or on mobile phones) influences these relationships. In this review, relationships of gaming with hearing loss or tinnitus were observed in studies that focused on gaming centres and PC gaming. However, most studies provided few details on the type of gaming and the setting in which it occurred, which highlights the need for future research to comprehensively evaluate these relationships. In addition to differences in study methodology, inconsistencies in research may be explained by the incremental and progressive nature of noise-induced hearing loss,72 which makes it difficult to capture short-term effects of sound or noise exposure, particularly in young people.

The WHO has recognised unsafe listening practices as an important global public health problem, given the negative consequences of sound or noise exposure on auditory and non-auditory health,7 and the fact that these consequences can be prevented through the practice of safe listening.2 6 The WHO ‘Make listening safe’ initiative, launched in 2015, aims to ensure that individuals of all ages can enjoy listening while protecting their hearing.7 A primary goal of ‘Make listening safe’ is to empower individuals to make choices that will regulate exposure to high-intensity sounds via education and provision of relevant resources.2 3 6 For example, materials available to the general public can be used to promote preventative strategies for individuals, and include recommendations such as limiting the time spent engaging in noisy activities, and keeping the volume at safe levels.

Along with the ‘Make listening safe’ resources available to individuals,2 there are global standards, including ‘Guidelines for safe listening devices/systems’ (ITU-T H.870) to describe requirements for safe listening on devices and systems, particularly those that play music.15 However, at this time, these guidelines do not apply to gaming consoles or devices. Importantly, to the authors’ knowledge, there are little to no global policy recommendations that focus on promoting safe listening among gamers. Results from this review suggest that policy development focused on safe listening among gamers at high risk for developing hearing loss and/or tinnitus, following the necessary supporting research, is warranted.

Conclusions

The limited available evidence suggests that gaming may be a common source of unsafe listening, which could place many individuals worldwide at risk of hearing loss and/or tinnitus. Results suggest that additional research on these relationships is needed, including identifying populations of gamers at high risk of unsafe listening. These would help to inform and refine interventions that can prevent hearing loss and/or tinnitus among gamers. An important intervention could be the development and implementation of policy to promote safe listening among gamers.