"There are more important things to worry about": attitudes and behaviours towards leisure noise and use of hearing protection in young adults.

OBJECTIVE
Noise-induced hearing problems among young adults are increasing due to participation in loud activities. This study explored attitudes towards leisure noise, hearing protection, and perceived susceptibility to noise damage in young adults with no diagnosed hearing problems. Understanding attitudes and behaviours will assist with the future development of strategies to improve awareness and use of hearing protection.


DESIGN
A qualitative study.


STUDY SAMPLE
Four focus groups, with 28 adults aged 18-35 years (6 male; 22 female; mean age 23 years).


RESULTS
Using framework analysis, five themes emerged. Earplug use occurred when participants had experienced previous temporary hearing damage (i.e. short-lived tinnitus or hearing loss). Others chose not to use earplugs because music venues are expected to be loud. Peer behaviours and opinions also had a strong influence over earplug use. A lack of knowledge of hearing-related damage resulted in a lack of concern for hearing health and other health conditions taking priority.


CONCLUSIONS
The challenge is to present hearing health messages that are relevant and accessible to young adults. Music and entertainment venues must also take greater responsibility to protect the hearing of its customers by at least informing visitors of the dangers of loud music.


Introduction
The World Health Organisation (Hellmuth, Classen, and Kim 2012) states that the adverse health effects of noise pollution include cardiovascular disturbances, cognitive impairment, poor mental health, and negative social behaviour, as well as hearing impairment and sleep disturbances. This paper will focus on the adverse effect noise pollution has on hearing impairment. Exposure to loud noise can cause noise-induced hearing loss (NIHL), which is a permanent hearing impairment resulting from prolonged exposure to high levels of noise (Clark 1991), and tinnitus; the perception of sounds in the head or ears in the absence of an external noise (Baguley, McFerran, and Hall 2013). In 2015, it was estimated that as many as 1.1 billion people could be at risk of developing NIHL (World Health Organization 2015). This is a significant social and public health problem. Those with hearing problems are more likely to experience reduced quality of life and social isolation , and depression and anxiety  than those without hearing problems, including young people who have experienced permanent hearing-related symptoms as a result of loud music (Vogel et al. 2014).
Noise exposure can be through occupational settings, or recreational venues such as concerts and nightclubs. Within the context of UK laws, in the workplace there are hearing protection regulations to protect employees from noise damage. The Control of Noise at Work Regulations 2005 ensure that workers' hearing is protected from excessive noise at their place of work, which could cause them to lose their hearing and/or to suffer from tinnitus. From 2008, this included people working in the music and entertainment sectors. However, unlike workers, there is no specific legislation setting noise limits for the audience exposed to noise, only recommendations. The Health and Safety Executive in the UK recommends that the sound level in any part of the audience area should not exceed 107 dB. However many venues exceed this with noise levels reaching up to 112 dB in nightclubs (Serra et al. 2005), thus posing a significant risk of hearing problems (Potier et al. 2009).
Most noise exposure among young adults is caused by voluntary participation in activities where music is played at loud volume (Daniel 2007). In recent years, there has been an increase among the younger generation of exposure to loud noise and an increase in noise induced hearing problems (Henderson, Testa, and Hartnick 2011;Shargorodsky et al. 2010;le Clercq et al. 2016). However, among young adults, the risk of hearing loss is not perceived to be of high personal relevance (Vogel et al. 2008). When young adults have been questioned about hearing problems that can occur when noise is too loud, only 15% considered tinnitus as a symptom to be concerned about (Crandell, Mills, and Gauthier 2004). Furthermore, very few young adults will take preventative action to reduce the risk of NIHL (Bogoch, House, and Kudla 2005). The use of earplugs among young adults in music venues is reported to be low (de Lourdes Quintanilla-Dieck, Artunduaga, and Eavey 2009;Gilles et al. 2013;Gupta et al. 2014). An online survey of 1200 young Australians found that the majority of participants did not perceive themselves at risk and had low levels of engagement in noise reduction (Gilliver, Beach, and Williams 2015). It is also likely to be difficult to achieve voluntary behaviour change because visiting discotheques becomes habitual for many adolescents (Vogel et al. 2010).
Those who do use earplugs are more likely to have experienced hearing symptoms, e.g. tinnitus, noise sensitivity or temporary hearing loss; and are more likely to be aware of the risks of noise and the importance of hearing protection (Widén 2013;Gilliver, Beach, and Williams 2015;Degeest et al. 2017). Beach, Williams, and Gilliver (2012) concluded that for some people, experiencing hearing symptoms acted as a ''wake-up call'' and was a motivator for protecting their hearing during concerts. However, other studies have found that even those with NIHL (Hunter 2017), or those who are aware of the risks (Beach, Gilliver, & Williams 2013), do not necessarily take steps to protect themselves from hearing-related damage.
The theory of planned behaviour is often used to understand factors relating to behaviour change (Ajzen 1991). The model states that intention to change a behaviour is related to attitudes (positive or negative beliefs about performing the behaviour), subjective norms (the extent to which an individual's perception about the particular behaviour is influenced by significant others, e.g. parents, peers, teachers, etc.), and perceived behavioural control (the ease or difficulty of performing the particular behaviour). The question is whether increasing awareness of the risks of leisure noise exposure, and increasing opportunities for protective behaviours could have a positive impact on young adults' leisure noise behaviours. In one recent study (Nielsen, Beach, and Gilliver 2014), increasing opportunities for protective behaviours had a positive impact on young adults' behaviours with regards to noise exposure. Regular nightclub attendees were given earplugs to wear for a 16-week trial and there was a significant improvement in comfort and music enjoyment, showing that those who have experience with earplugs can have sustained positive attitudes towards the devices (Nielsen, Beach, and Gilliver 2014).
Hearing education campaigns also have the potential for positive behaviour change by increasing knowledge of the risks of loud music exposure. A governmental preventive campaign, focussing on the harmful effects of recreational noise and the use of hearing protection in Belgium, resulted in a significant change in attitudes (Gilles and Paul 2014). Negative attitudes towards noise and positive attitudes toward hearing protection increased in a cohort of students aged 14-18 years. Keppler, Ingeborg, and Sofie (2015b) also found that a hearing education programme designed for young adults resulted in a decrease in recreational noise exposure, attitudes towards noise and a modest increase (12%) in use of hearing protection devices, after six months. However, other studies (Weichbold and Zorowka 2007) have found no difference in music-related behaviour one year after a hearing education campaign.
Much of the research on attitudes towards leisure noise, hearing loss and hearing protection has been conducted in the US (Crandell, Mills, and Gauthier 2004;de Lourdes Quintanilla-Dieck, Artunduaga, and Eavey 2009), Australia (Beach, Williams, and Gilliver 2012;Beach, Gilliver, and Williams 2013;Nielsen, Beach, and Gilliver 2014;Gilliver, Beach, and Williams 2015), and some European countries, e.g. Belgium (Gilles and Paul 2014;Keppler, Dhooge, and Vinck 2015a;Keppler et al. 2015b), and the Netherlands (Vogel et al. 2008(Vogel et al. , 2009a(Vogel et al. , 2009b(Vogel et al. , 2010(Vogel et al. , 2014. Research in the UK is limited. Besides the Plug'Em Campaign (British Tinnitus Association 2016), few educational hearing programmes exist in the UK. The culture and social norms of young adults' behaviour with regards to nightclubs and hearing protection may be different in the UK.
A better understanding of young adults' attitudes and behaviours will assist with the future development of strategies to improve awareness and use of hearing protection specifically for this population. This study is in the context of the culture and laws of the UK. The aim was to explore attitudes and behaviours towards leisure noise and use of hearing protection, specifically earplugs, among young adults with no known hearing loss or tinnitus. Using qualitative research methods, the study aimed to address the following questions: (1) What attitudes do young adults have towards leisure noise and hearing damage, (2) and what are the motivating and inhibiting factors for engaging in protective hearing behaviours.

Recruitment
Young adults aged between 18 and 35 years with no known hearing impairment or tinnitus were recruited via advertisements asking for participation in a focus group concerned with involvement in noisy leisure activities. Participants responded to the advertisement by contacting the researcher and indicating their preferred focus group session. Informed written consent was obtained from all participants. The focus groups were conducted in March and April 2016. Participants received a £20 inconvenience voucher for taking part. Ethical approval was received from the University of Nottingham School of Medicine ethics committee.

Participants
In qualitative research there are no specific rules for determining an appropriate sample size. Often time constraints, available resources Abbreviation BTA British Tinnitus Association NIHL Noise induced hearing loss NIHR National Institute for Health Research NHS National Health Service and study objectives determine sample size (Patton 1990). Glaser and Straus (Glaser, Strauss, and Strutzel 1968) recommend the concept of data saturation (i.e. no new themes are emerging) for achieving an appropriate sample size in qualitative studies. Our study comprised four focus groups with 28 young adults aged between 18 and 35 years (6 male; 22 female; mean age 23 years). Two were members of staff at the University. The others were undergraduate and postgraduate students. There was one group of five, two groups of seven, and one group of nine people. None of the participants had permanent hearing loss or tinnitus (as diagnosed by a clinician), but some did comment they had occasionally experienced temporary tinnitus after a night out. Saturation was reached after conducting four focus groups.

Measures
The focus groups were conducted by the researcher who had experience in facilitating focus groups and qualitative data analysis. The focus groups lasted between 25 and 45 min. All interviews were recorded and transcribed. The researcher had no personal or professional relationship with the participants. During the focus groups, the participants discussed the following issues: The reasons for, as well as the frequency and duration of visits to noisy leisure venues. Attitudes towards the noise levels in leisure venues The benefits and barriers associated with earplugs Their perceived risk of noise-induced hearing problems

Data analysis
The interviews were transcribed verbatim by a professional third party (UK transcription). Transcripts were read carefully and notes taken before analysis began. NVivo qualitative data analysis software was used for managing the data coding and analysis process. A ''Framework'' analytic approach (Ritchie, Spencer, and O'Connor 2003) was adopted. This is a very systematic structured data analysis method suitable for research where questions or issues are identified in advance and then systematically considered in the analysis, while still retaining flexibility for data saturation of patterns or themes that are identified through focus groups (Ritchie, Spencer, and O'Connor 2003). It is becoming more widely used in health research. The key steps involved are familiarisation, identifying a thematic framework, indexing, charting, mapping and interpretation. The framework approach resulted in themes that were driven by a combination of the study aims and other new findings that arose naturally through the focus group discussions. Demonstrating rigour in qualitative research is challenging because there is no accepted consensus about the standards by which such research should be judged (Rolfe 2006). Ideally in qualitative research a second coder also carries out the data analysis in order to verify the findings and increase validity. However, due to financial constraints we were not able to have a second coder. Steps were taken to enhance the credibility of the findings: Rich and thick verbatim extracts from participants have been included to support the findings and the author repeatedly revisited the data and engaged in constant comparison to verify the findings throughout the data analysis. Furthermore, the steps involved in the framework approach allow the researcher to maintain an effective and transparent audit trail, and this enhances the rigour of the analytical processes and the credibility of the findings.

Results
Initially participants were asked to comment on venues they visit where they perceive the noise to be loud, and the duration and frequency of such visits. Participants listed leisure/social venues such as bars, clubs, restaurants or the cinema; music orientated venues such as gigs, concerts, festivals and using personal stereos; and sporting venues such as football grounds, hockey grounds, and the gym. Frequency of visits ranged from ''very occasionally'' to ''four times a week'', and duration would typically range from 2 to 4 h.
Five over-arching themes emerged from the data in relation to attitudes and behaviours towards leisure noise and hearing protection: (1) enjoying loud music; (2) previous hearing damage; (3) peer behaviours and opinions; (4) lack of knowledge and concern; (5) hearing is not a priority. Figure 1 shows how these themes are connected. The participant's discussions relating to each of the five themes are presented below. The themes related to earplug use are shown in bold, with sub-themes italicised. Examples of participant comments are included throughout to illustrate the findings.

Enjoying loud music
A positive attitude towards noise was expressed by many of the participants. They enjoyed loud music because it enhanced the experience of the leisure activity and had a positive impact on their mood. Participants enjoyed loud music in many different situations, e.g. when driving; in a nightclub; listening to live music or personal stereo; or when exercising because it can ''increase adrenaline and set your mood''. There was the opinion that loud noise is expected and part of the experience when you go to certain venues such as concerts, clubs, and festivals, and this adds to the enjoyment and creates a better atmosphere: If you're in a nightclub you expect it to be quite loud because that's the point of it, like to immerse yourself in the music. . .it's like being in the zone isn't it.
Some participants described their ''love'' and ''passion'' for music, and felt that the benefits of loud music were much more important than the potential risks: The benefits outweigh the risks listening to it at a certain volume, it definitely would compromise the experience having to turn it down.
As there was the expectation that clubs and concerts should be loud, there was the opinion that wearing earplugs would ''take away from the experience''.
For me when I go to a concert or a club I expect it to be loud so I would never wear ear protectors because I know it's going to be loud, that's part of going.
People also had the impression that earplugs would have an effect on the quality of the music, causing it to sound ''muffled'', or unclear: I've gone to enjoy the gig and the sound, that's the whole point of the band, I want to hear it as they would intend me to hear it.
For others, who also enjoyed loud music, earplugs were used in order for them to continue listening to loud music without the worry that it could be damaging their ears. The earplugs offered ''safety and protection''. One person commented that he used earplugs in a particular venue because it was ''ridiculously loud'' that he knew it must be causing damage to his ears, so he used earplugs as protection: The advantage is it's going to help reduce it [hearing damage]. . .it's going to prolong the hearing.
He also felt that it made the music sound ''clearer'': You hear better. . .that bass isn't in your ears, it's just pure music and it's good.
Many participants felt that it is the responsibility of the individual to protect their hearing, and if somebody finds it too loud then it is up to that person to find a solution rather than limit the enjoyment for everyone else, because clubs and concerts are expected to be loud.
For me it's not an issue, but I don't see why if it was an issue for someone, why my take on the performance or wherever we are should be limited because the person next to me says it's too loud.
. . .it's that loud because people want it to be that loud. . .it's peoples individual responsibility if they decide that it's too loud they have to do something about it, because the majority of the people at the gig or club would be disappointed if you turned the volume down.

Previous hearing damage
Some people expressed concern about the potential dangers of noise exposure. On occasion some participants had negative attitudes towards noise when there were unpleasant physical consequences such as feeling their body shaking; experiencing pain, temporary hearing loss or ringing in the ears; and feeling the ground vibrate: When you can feel your body shaking because of the bass, it's too much.
Some people were concerned because ''it's not normal for your ears to ring''. Others were concerned because they had noticed a deterioration in their hearing since being at University because ''you're constantly going out''.
I feel like mine's [hearing] getting worse. I notice it more when I go to a gig, like last night I went somewhere and afterwards my head was hurting, my ears were hurting. . .I was like, this is happening more, so maybe something is being affected, I don't know.
Despite this concern, very few people actually wore earplugs, and many reported they would simply ''put up with it [loud noise]''. However, the physical effects of the loud noise can impact on the enjoyment of the event and some people would take other precautions such as distancing themselves from the noise by leaving early or moving to the back. This can be very disappointing for people who have paid a lot of money to see a band.
. . .even just down a little I think you can still really enjoy the bands. . .It's this constant extreme loud noise. . .just too much. . .it's a disappointment when you've paid a good chunk of money.
Those that had experienced more severe signs of damage from previous exposure to loud music, were much more aware of the potential risks and reported using earplugs on a few occasions:  I was in a concert in Portugal, in a pretty small place and I started bleeding from my right ear. . .so I freaked out and I left. . .I now try to wear earplugs in concerts.

Peer behaviours and opinions
Attitude from others was an important factor when considering whether to wear earplugs. What their peers think and do is an ''important part of the decision''. They would not want to be the only person in their circle of friends wearing earplugs. . . .if your friends did it then you would do it. . .that's just how it goes. . .You wouldn't want to be the odd one out.
There is still a stigma attached to wearing earplugs. People were concerned about getting ''funny looks'' from other people if they turned up at a nightclub with earplugs in. They were concerned that they look ''odd'' on a night out: I don't think you want to go to a club and have you're make up, your hair done, your earrings and then have little things popping out of your ears. . .you want to look good, you want to hang out, you want to socialise.
Participants weren't necessarily against wearing earplugs, but if no one else in their group of friends did then it meant they would be very unlikely to.

Lack of knowledge/lack of concern
The analysis of these focus groups revealed there is a clear lack of knowledge concerning the potential damage that noise can do, and therefore individuals own susceptibility to hearing loss and tinnitus. It was evident that may people did not have good knowledge of hearing problems. Some people asked ''what is tinnitus?''; ''is it permanent?''; ''can you get rid of it?'' Participants were unsure what a safe decibel level is. They were unsure how much exposure to music can be damaging. This was frustrating for people because they didn't feel fully informed of what the dangers could be: I personally don't have any idea how loud it has to be to have an effect, how many times, how much I'd have to be exposed to it before it started to have an effect.
For other people, as they didn't know enough about the potential implications of noise damage it wasn't something that really concerned them. Even though some participants had experienced temporary hearing loss or tinnitus after a night out, it was not a concern for many people. There was the view that it is expected after a night out, and something they put up with in order to enjoy loud music.
You just accept that it [tinnitus] happens after a night out sometimes. It doesn't happen all the time, it's just every once in a while it might happen and you accept it.
Experiencing temporary hearing problems was seen as part of the ''territory'' of going to these venues. Noise damage was not viewed as a serious issue for some people because going to loud venues is not an everyday occurrence. As it is infrequent, there is the perception that it won't cause any damage and is nothing to be concerned about.
I don't want to be deaf but I don't think going to a club once a week would make me deaf.

Hearing problems are not a priority
The participants in this study did not consider hearing problems to be a priority when there are other more important things to be concerned about I'm more concerned about the alcohol that I'm consuming and what that will do to me than the loud music.
As one person stated: There are a lot of things to worry about and that's [hearing] not high up in a lot of people's lists.
As the risk of noise induced hearing problems was not a priority, people were unwilling to compromise their lifestyle or sacrifice the enjoyment of loud music: I'm aware that it is probably not doing my ears much good but there are a lot of things to worry about and I really enjoy music, so I'm going to choose to put the music on a bit louder and enjoy it. . .rather than decide that it's not best for my hearing.
Additionally, many of the participants had little experience of hearing loss, besides elderly relatives. Consequently, there was the view that hearing problems are an older person's illness and not something to be concerned about at a young age: Especially at our age, no one worries about losing their hearing. . .we think that's a problem for older people. . .take it for granted.
Young people take their hearing for granted, and as they don't have any peers affected by hearing problems, it was hard for them to imagine they could be putting themselves at risk. I think that's because you don't see it around you as well. The people that you spend the most time with, no one is affected. . .everyone is affected by so many things but not hearing so it's never something that comes up on your register.
Furthermore, hearing damage is not immediate, so young people do not think about what could happen in the future: Because it's not an immediate problem. . .It's not like you turn up the music, you go deaf immediately. . .people are not really thinking about 30 years down the line As many of the participants had not experienced any significant hearing symptoms, and had no peers with hearing problems, it was hard for them to relate to what it would be like to have hearing problems. As a result they were unlikely to change their behaviour: It's like with anything, until something happens with most people, especially with the young, until something happens you never think about it.
Because hearing problems were not a priority for the participants, and because of their limited knowledge of the risks associated with loud music, many participants thought that there should be an increase in awareness and education around the topic. They felt that some legislation or guidelines could be helpful, to increase knowledge. Noise damage is not given the same focus and attention from the government and media: With alcohol. . .it's quite well publicised the number of units people should have per week. Even if people don't adhere to that. . .they at least have an awareness of how unhealthy their drinking is. . .but I would have no idea about how much I would have to compromise my lifestyle to prevent potential [hearing] damage.
If a similar approach is given to hearing health then people will be in a better position to understand the risks and how to protect their hearing. Participants said they would welcome ''more education'' on the risks of noise exposure so they could be ''more informed''. Being better informed would mean people can decide for themselves what action to take: It certainly would raise people's awareness of what they're being exposed to and they can choose for themselves with more knowledge what they'd like to do.
With greater awareness over the dangers of noise exposure, people will start to see their hearing as a priority and will be able to make better educated informed decisions regarding their hearing health. If there is increased awareness, then attitudes might change, and there may be less stigma attached to wearing earplugs: Maybe if more people were doing it and maybe if more people realised the consequences of loud music, then maybe we would pay more attention and maybe wearing earplugs in a nightclub wouldn't be such a thing.

Discussion
The aim of this study was to explore attitudes and behaviours towards leisure noise and use of hearing protection among young adults with no known hearing loss or tinnitus. Focus groups provided a rich setting for participants to share their opinions.
The participants generally had positive attitudes towards noise, in that they enjoyed loud music and considered themselves music lovers. Many young people believe music is enhanced when played very loudly (Mercier and Hohmann 2002). The participants shared the opinion that there is an expectation that clubs and concerts will be loud and this is part of the experience. This finding is similar to a study in the US with 700 young adults in which the majority were regular attenders of discotheques and rock concerts and did not consider the noise to be too loud (Mercier and Hohmann 2002).
Participants were concerned that earplugs would have an effect on music quality by reducing the clarity of the music. As participants considered themselves music lovers they placed more importance on their lifestyle, enjoyment and love of loud music, than on their hearing. However, a love of music was also a motivating factor for earplug use for some participants who had experienced injury from noise, in order to prevent further damage. This is consistent with other research (Beach, Williams, and Gilliver 2012). Those who have experienced hearing problems as a result of noise are more likely to use earplugs (Bogoch, House, and Kudla 2005;Laitinen 2005;Hunter 2017).
On occasion participants reported having negative attitudes towards noise in a particular venue that is very loud or when they experienced temporary hearing problems. This sometimes resulted in protective behaviours such as distancing themselves from the noise by moving to the back, leaving early, or taking breaks. However, few people actually wore earplugs. Many young people have little experience with earplugs because there is still a stigma attached to wearing them; and they did not have any friends who wore them. Peer norms and behaviours were a significant factor in the decision to not wear earplugs as they wouldn't want to be the only person in their peer group wearing them, for fear of looking odd and getting teased. This finding is in line with Widén (2013) who suggested that social norms were more important than attitudes in relation to using hearing protection. It has been shown consistently that those who are concerned about their appearance are significantly less likely to wear earplugs, even if provided free (Bogoch, House, and Kudla 2005).
The analysis of these focus groups also revealed that although there was recognition that loud noise could potentially cause damage, there was a clear lack of knowledge concerning the potential damage that noise can do and their own susceptibility to hearing loss and tinnitus. Many people did not understand what tinnitus is, or what exposure levels could cause damage, or how those symptoms might present themselves. They felt their personal risk of hearing damage was low due to the infrequency of exposure. There was the view that going out once or twice a week would not cause any damage and hearing loss was considered an old persons illness and not something to worry about at a young age. For people who have never experienced tinnitus or hearing loss and have no peers with hearing problems it can be hard to appreciate the risk to self of developing hearing problems. In the current study, exposure to loud noise was not viewed as something to be concerned about, perhaps due to their limited experience of hearing problems. Where people have experienced permanent signs of damage after previous exposure to loud music, they are more likely to be aware that noise damage is irreversible and permanent, and to be concerned about hearing damage and wear earplugs (Beach, Williams, and Gilliver 2012).
Because of a lack of knowledge and concern over the consequences of noise damage and hearing problems, many young people felt there were more important things to worry about. Hearing problems were not viewed as a priority when there are other behaviours such as smoking, alcohol and drug use that are given much more attention and focus in society. In the United States, a study found that potential hearing loss as a result of loud music is low in priority compared to other general health issues (de Lourdes Quintanilla-Dieck, Artunduaga, and Eavey 2009). A survey conducted online with over 9000 responses also found that most young people did not consider hearing loss a major concern (Chung et al. 2005), and prioritised other health issues such as sexually transmitted diseases, alcohol intake, drug use, depression, smoking, and nutrition and weight issues.
This study is not without its limitations. Focus groups have the potential to involve self-presentation biases, and the influence of peers opinions can lead to conformity of views. However there was disagreement within the focus groups, so it is probable that participants did actually discuss their true opinions. Additionally, due to the nature of focus groups, it was not possible to compare the attitudes and behaviours of those with low attendance with those with frequent attendance of loud leisure venues. Although many participants stated how frequently they visit loud venues, focus group data is analysed as a whole and not individually. A further limitation is that the sample was drawn from one University and these participants are therefore not representative of young adults in general. It is also possible that there is a bias in terms of those who volunteered to take part. However, the goal of qualitative research is not to collect a representative sample, but rather to describe participant's experiences, whereby the results can inform the design of quantitative studies which can be generalisable. A further limitation is the lack of a second coder during data analysis. However steps were taken to enhance the credibility of the findings (as mentioned in the methodology).
Nonetheless, these findings have important implications for hearing education programmes among young adults. First and foremost, knowledge and awareness about the damaging effects of leisure noise needs to increase among young adults. With increased awareness and knowledge, people will be better informed, and in a better position to consider how best to protect themselves from noise damage. As hearing problems are irreversible, it is essential for people to take steps to protect their hearing before they experience any symptoms. As earplugs have been found to be effective in preventing temporary hearing loss after loud music exposure (Ramakers et al. 2016), it is imperative that earplug use is promoted in young adults, and people who attend loud music events. Such information could be circulated at schools and Universities offering the opportunity to reach large numbers of people. Music venues could also do much more to protect the hearing of its customers, including ensuring loudspeakers are placed away from visitors, and have separate spaces away from the noise to allow people to give their ears ''a break'' (Vogel et al. 2009a). As a minimum, venues should inform their visitors of the potential risks for hearing loss and/or tinnitus, and warn visitors about the dangers of being exposed to loud volume music (Vogel et al. 2009b).
Hearing protection campaigns such as Adopt-a-band (Auchter and Le Prell 2014), Dangerous Decibels (Martin et al. 2006) and The Sound Sense (Neufeld et al. 2011), all in the US, can increase knowledge of the association between leisure noise exposure and hearing damage, and promote the use of hearing protective devices. However, it is worth noting that increased awareness, through educational hearing campaigns, does not necessarily increase the use of hearing protection devices (Keppler, Dhooge, and Vinck 2015a). Considering even those with noise-induced hearing problems do not always recognise the importance of protecting their hearing (Hunter 2017), the challenge for hearing health promotors to increase protective behaviours regarding hearing remains difficult. In order to achieve any significant long lasting change in young adults' leisure noise behaviour, it is imperative that preventive work also tackles societal norms and regulations, as well as individual behaviour change through increasing awareness and knowledge of the risks of loud music exposure.
Declaration of interest: No potential conflict of interest was reported by the author. This work was supported by British Tinnitus Association.