Effects of Early Smoking Habits on Young Adult Female Voices in Greece * , †Dionysios Tafiadis, * , †Eugenia I. Toki, ‡Kevin J. Miller, and * , †Nausica Ziavra, *†Ioannina, Greece, and ‡Seward, Nebraska Summary: Cigarette use is a preventable cause of mortality and diseases. The World Health Organization states that Europe and especially Greece has the highest occurrence of smoking among adults. The prevalence of smoking among women in Greece was estimated to be over 30% in 2012. Smoking is a risk factor for many diseases. Studies have demonstrated the association between smoking and laryngeal pathologies as well as changes in voice characteristics. The purpose of this study was to estimate the effect of early smoking habit on young adult female voices and if they perceive any vocal changes using two assessment methods. The Voice Handicap Index and the acoustic analyses of voice measurements were used, with both serving as mini-assessment protocols. Two hundred and ten young females (110 smokers and 100 nonsmokers) attending the Technological Educational Institute of Epirus in the School of Health andWelfare were included. Statistically significant increases for physical and total scores of the Voice Handicap Index were found in the smokers group (P < 0.05). Significant changes were observed for the acoustic parameters between smoker and nonsmoker groups. The results of this study indicated observable signs of change in the voice acoustic characteristics of young adults with early smoking habits. Key Words: Acoustics–Computerized voice analysis–Smoking–Voice characteristics–Voice Handicap Index. INTRODUCTION Voice disorders result from changes in the voice mechanism, 1,2 leading to vocal inefficiency. 3 Previous studies indicated that the prevalence of voice disorders is approximately 9%, 4 with women having a higher occurrence of voice disorders. 5 Epidemiologic studies also reported a positive association of smoking with approximately 40 causes of morbidity and mortality, 6–8 and a high prevalence of tobacco use in adults. 9–12 According to the World Health Organization, 9 Greece has the highest incidence of tobacco smoking at 42.4%. Another study also estimated that cigarette smoking for women in Greece ex- ceeded 30%. 10 Smoking is a high-risk factor influencing voice and its characteristics. 13–15 The relationship between smoking and changes in the larynx leading to voice disorders is evident. 16–18 It has been well documented that lesions of the larynx linked to smoking habits could result in vocal polyps, 17 Reinke edema, 19 vocal fold carcinomas, 18,20,21 chronic inflammation, erythema, or irritation of laryngeal mucosa. 21–23 Chai et al 24 found that smoking affects perceptual, acoustic, and aerodynamic performance. Further- more, changes were found in fundamental frequency (F0), 25–27 jitter, and shimmer. 12,13 People, including smokers, having voice symptoms can be evaluated with various methods. These methods are composed of: (1) imaging techniques 28–33 ; (2) aerodynamic, 33–36 acoustic, and perceptual analyses 36–40 ; and (3) self-evaluation question- naires, such as Voice Handicap Index (VHI). 41–49 Although previous research recognized the effect of smoking on voice characteristics, no study to this point has estimated the influence of early smoking on voice characteristics. The purpose of this research was to estimate the effect of an early smoking habit on VHI scores and acoustic voice parameters for young adult females. MATERIALS AND METHODS Participants Two hundred and ten young adult females (110 smokers and 110 nonsmokers) were recruited from the School of Health and Welfare at Technological Educational Institute of Epirus. Par- ticipants had no history of laryngeal or respiratory system disorders 2 weeks before enrollment and those who did were excluded. In addition, participants who reported symptoms cor- related to gastroesophageal reflux disease or laryngopharyngeal reflux, or drug or alcohol abuse were not included. Smokers were considered those who smoked at least two cigarettes daily for at least one consecutive year prior to the study. Nonsmokers were those who never smoked. Data collection All participants completed the Greek version of VHI. 49 It con- sists of 30 items, divided into three domains: emotional (VHI- E), physical (VHI-P), and functional (VHI-F). Voice sampling was obtained in a quiet room (<40 dB) 50 in accordance with the National Center for Voice and Speech recommendations. 51,52 The recordings were done using a Mai CM—903 electret condens- er meeting microphone (Tiger Electronics Inc., North Reading, MA) placed at least 10 cm away from each participant’s mouth. 50 Participants were allowed to rehearse before their final mea- surement. They were asked to sustain /a/ and /e/ for at least 5 seconds. Schutte and Seidner 50 recommended sustaining /a/, /i/, Accepted for publication March 21, 2017. Conflict of interest: All authors declare no conflicts of interest in this paper. From the *Laboratory of Audiology, Neurootology and Neurosciences, Department of Speech & Language Therapy, Technological Educational Institute of Epirus, Ioannina, Greece; †Laboratory of New Approaches in Communication Disorders, Department of Speech & Language Therapy, Technological Educational Institute of Epirus, Ioannina, Greece; and the ‡Department of Special Education, Concordia University, Seward, Nebraska. Address correspondence and reprint requests to Eugenia I. Toki, Laboratory of Audiology, Department of Speech & Language Therapy, Technological Educational Institute of Epirus, 4th Km Ioaninna, Athens Road, P.C. GR455 00 Ioannina, Greece. E-mail: toki@ioa.teiep.gr Journal ofVoice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2017.03.012 ARTICLE IN PRESS