Prevalence and Determinants of Tinnitus in the Italian Adult Population

Abstract

Limited, outdated, and poor quality data are available on the prevalence of tinnitus, particularly in Italy.
A face-to-face survey was conducted in 2014 on 2,952 individuals, who represented the Italian population aged 18 or more (50.6 million). Any tinnitus was defined as the presence of ringing or buzzing in the ears lasting for at least 5 min in the previous 12 months.
Any tinnitus was reported by 6.2% of Italian adults, chronic tinnitus (i.e. for more than 3 months) by 4.8%, and severe tinnitus (i.e. which constitutes a big or very big problem) by 1.2%. The corresponding estimates for the population aged ≥45 years were 8.7, 7.4 and 2.0%, respectively. Multivariable analysis on population aged ≥45 years revealed that old age (odds ratio (OR) = 4.49 for ≥75 vs. 45-54 years) and obesity (OR = 2.14 compared to normal weight) were directly related to any tinnitus, and high monthly family income (OR = 0.50) and moderate alcohol consumption (OR = 0.59 for <7 drinks/week vs. non-drinking) were inversely related.
This is the first study on tinnitus prevalence among the general Italian adult population. It indicates that in Italy tinnitus affects more than 3 million adults and is felt as a major problem by more than 600,000 Italians, mostly aged 45 years or more. © 2015 S. Karger AG, Basel.

Full text

E-Mail karger@karger.com
Original Paper
Neuroepidemiology
DOI: 10.1159/000431376
Prevalence and Determinants of Tinnitus
in the Italian Adult Population
SilvanoGallus  a AlessandraLugo  b WernerGaravello  c CristinaBosetti  a
EugenioSantoro  a PaoloColombo  d PaolaPerin  e CarloLaVecchia  b
BertholdLangguth  f 
a  Department of Epidemiology, IRCCS – Istituto di Ricerche Farmacologiche ‘Mario Negri’, b  Department of Clinical
Sciences and Community Health, University of Milan,
c  Department of Surgery and Translational Medicine,
University of Milano-Bicocca,
d  Istituto DOXA, Worldwide Independent Network/Gallup International Association
(WIN/GIA), Milan , and
e  Department of Brain and Behavioural Sciences, University of Pavia, Pavia , Italy; f  Department
of Psychiatry and Psychotherapy, University of Regensburg, Regensburg , Germany
This is the first study on tinnitus prevalence among the gen-
eral Italian adult population. It indicates that in Italy, tinnitus
affects more than 3 million adults and is felt as a major prob-
lem by more than 600,000 Italians, mostly aged 45 years or
more. © 2015 S. Karger AG, Basel
Introduction
Tinnitus, a symptom of various underlying patholo-
gies, is defined as the perception of sound, typically a
ringing, buzzing, or whistling sound, in the absence of a
corresponding acoustic external stimulus
[1, 2] .
Inadequate and poor-quality data are available on the
epidemiology of tinnitus (e.g. prevalence, aetiology, and
potential treatments). This is, at least in part, a conse-
quence of the subjective nature of tinnitus assessment, the
heterogeneity of the question used to define the presence
of tinnitus, and the large variety of tinnitus characteristics
[3] and associated disorders [4] .
K n o w l e d g e o n t h e b u r d e n o f t i n n i t u s i n t h e g e n e r a l
adult population comes from a few large prospective stud-
ies, mostly from northern Europe and the United States,
Key Words
Tinnitus · Prevalence · Risk factors · Italy · Representative
survey · Epidemiology
Abstract
Background: Limited, outdated, and poor quality data are
available on the prevalence of tinnitus, particularly in Italy.
Methods: A face-to-face survey was conducted in 2014 on
2,952 individuals, who represented the Italian population
aged 18 or more (50.6 million). Any tinnitus was defined as
the presence of ringing or buzzing in the ears lasting for at
least 5 min in the previous 12 months. Results: Any tinnitus
was reported by 6.2% of Italian adults, chronic tinnitus (i.e.
for more than 3 months) by 4.8%, and severe tinnitus (i.e.
which constitutes a big or very big problem) by 1.2%. The
corresponding estimates for the population aged ≥ 45 years
were 8.7, 7.4 and 2.0%, respectively. Multivariable analysis
on population aged ≥ 45 years revealed that old age (odds
ratio (OR)= 4.49 for ≥ 75 vs. 45–54 years) and obesity (OR=
2.14 compared to normal weight) were directly related to
any tinnitus, and high monthly family income (OR= 0.50)
and moderate alcohol consumption (OR= 0.59 for <7 drinks/
week vs. non-drinking) were inversely related. Conclusions:
Received: February 1, 2015
Accepted: May 10, 2015
Published online:   
Silvano Gallus, ScD
Department of Epidemiology
IRCCS – Istituto di Ricerche Farmacologiche ‘Mario Negri’
Via G. La Masa 19, IT–20156 Milan (Italy)
E-Mail silvano.gallus
 @  marionegri.it
© 2015 S. Karger AG, Basel
0251–5350/15/0000–0000$39.50/0
www.karger.com/ned

Gallus/Lugo/Garavello/Bosetti/Santoro/
Colombo/Perin/LaVecchia/Langguth
Neuroepidemiology
DOI: 10.1159/000431376
2
providing data on tinnitus incidence [5–7] . T o o u r k n o w l -
edge, only 20 previous studies from 14 countries reported
information on adult tinnitus prevalence using surveys re-
corded at a national or sub-national level. Online supple-
mentary table1 (www.karger.com/doi/10.1159/000431376)
shows the summary results from those surveys
[5, 8–25] .
Prevalence of tinnitus in adults ranged between 5 and 30%
and that of severe tinnitus from less than 1 to 7%.
In Italy, besides a few case series [26–30] or studies on
selected professional subgroups
[31] , information on tin-
nitus prevalence comes from 2 surveys. One investiga-
tion, conducted in Milan in 1981 on 1,473 adults, showed
a chronic tinnitus prevalence of 12% and severe tinnitus
prevalence of 3%
[24, 32] . Another survey, conducted in
5 Italian provinces in the 1990s on a sample of 2,216
adults, reported a prevalence of chronic tinnitus of 14.5%
[25, 32] . Both surveys showed a relatively high prevalence
of tinnitus, but since they were conducted in selected ar-
eas we cannot consider them to be representative of the
Italian general population.
In order to update the information on tinnitus in Italy
and to determine its socio-demographic and other indi-
vidual-level correlates, we analysed data from a represen-
tative survey of Italian adults conducted in 2014. More-
over, we compared tinnitus prevalence with the other
available prevalence estimates worldwide.
Methods
I n c o l l a b o r a t i o n w i t h D O X A – t h e I t a l i a n b r a n c h o f t h e w o r l d -
wide Independent Network/Gallup International Association –
during February to April 2014, we conducted a face-to-face survey
using a standardized methodology
[33, 34] . T h e s t u d y s a m p l e c o n -
sisted of 2,952 individuals (1,413 men and 1,539 women) aged 18 or
more, representative of the Italian adult population (i.e. 50.6 million
adults) in terms of sex, age, geographic area, and socioeconomic
characteristics. Participants were selected through a representative
multistage random sampling. The first stage was used to select mu-
nicipalities (the smallest Italian administrative division) in all of the
20 Italian regions (the largest Italian administrative division). Thus,
taking region and size as criteria, we identified 116 municipalities,
representative of the Italian universe of municipalities. In the second
stage, in each municipality, an adequate number of electoral wards
was randomly extracted (each ward corresponding to a given district
of each municipality), so that the various types of more or less afflu-
ent areas of the municipality were represented in the right propor-
tions (i.e. central and suburban districts, outskirts and isolated hous-
es). In the third stage, knowing the demographic structure of the
Italian population, adequate sex- and age-specific numbers of indi-
viduals were randomly sampled from electoral rolls. Unavailable
participants were replaced by their neighbours with the same sex
and age group. Statistical weights were used to assure the represen-
tativeness of the Italian population aged 18 years or more.
Ad hoc trained interviewers conducted interviews using a
structured questionnaire in the context of a computer-assisted
personal interview (CAPI). All interviews were conducted in the
houses of the selected individuals who accepted to participate to
the study. Besides general information on demographic and socio-
economic characteristics, we collected data on anthropometric
characteristics, tobacco smoking, and alcohol drinking. The ques-
tionnaire also included 3 direct questions about tinnitus
[35] . Par-
ticipants were asked about the presence of tinnitus as follows: ‘in
the past 12 months, have you been bothered by ringing or buzzing
in your ears or head that lasted for 5 min or more?’ Those who an-
swered ‘yes’ were enquired about their experience with tinnitus
with 2 further questions: the first one (i.e. ‘How long have you been
bothered by this ringing or buzzing in your ears or head?’) was
used to detect ‘chronic tinnitus’, defined as tinnitus duration of
3months or more; the second one (i.e. ‘How much of a problem is
this ringing or buzzing in one or both ears or in your head?’) was
used to assess severity of tinnitus: mild tinnitus was defined as re-
porting ‘no problem’ or ‘a small problem’, moderate tinnitus as
reporting ‘a moderate problem’, and severe tinnitus as reporting ‘a
big problem’ or ‘a very big problem.’
Education was categorized into low (no qualification up to mid-
dle school diploma), intermediate (high school), and high (univer-
sity). Geographic area was categorized as northern, central, and
southern Italy. Ever smokers (current and ex-smokers) were par-
ticipants who had smoked 100 or more cigarettes in their lifetime.
Ex-smokers were participants who had quit smoking at least 1 year
before the study, and current smokers were individuals continuing
smoking or having stopped less than 1 year before the study. Alco-
hol consumption was computed as the sum of the number of
drinks/week (around 12 g of alcohol) of 4 different types of alco-
holic beverages (i.e. beer, wine, spirits, and digestives). This variable
was then categorized into no alcohol drinking, consumption of
<7drinks per week (median value), and consumption of ≥ 7 drinks
per week. Body mass index (BMI) was computed as the ratio be-
tween self-reported weight (kg) and height (m
2 ), and categorized
into: underweight and normal weight (BMI <25.0 kg/m
2 ), over-
weight (25.0 ≤ BMI <30.0 kg/m
2 ), and obese (BMI ≥ 30.0 kg/m
2 ).
The net monthly family income was categorized according to ter-
tiles in the overall population aged ≥ 45 years (<1,160 EUR/month,
1,160–1,939 EUR/month, ≥ 1,940 EUR/month).
Statistical Analyses
Given the rarity of (severe) tinnitus among the young (18–44
years), we limited the multivariate analyses to middle-age and el-
derly adults ( ≥ 45 years). Odds ratios (ORs) for any, chronic and
severe tinnitus, and corresponding 95% confidence intervals (CIs),
were estimated using unconditional multiple logistic regression af-
ter adjustment for sex, age, level of education, geographic area,
smoking status, alcohol consumption and BMI. All the analyses
were performed with the SAS, version 9.2, statistical package (SAS
Institute).
Results
Table1 shows the prevalence of tinnitus overall and
according to its duration and severity. Among 2,952
Italian adults, 6.2% reported tinnitus in the past 12

Prevalence of Tinnitus in Italy Neuroepidemiology
DOI: 10.1159/000431376
3
months. Any tinnitus prevalence was 6.0% in men and
6.4% in women, and increased from 2.7% in individuals
aged 18–44 years, to 5.9% at 45–64 years, up to 12.3% at
≥ 65 years. Any tinnitus prevalence was 10.8% in individ-
uals aged 65–74, 13.2% in those aged 75–84, and 27.4% in
those aged ≥ 85 years. Overall, the prevalence of chronic
tinnitus was 4.8%. This prevalence was similar in men
(4.9%) and women (4.8%), and increased with increasing
age (1.3% in participants aged 18–44 years, 4.6% in 45–64,
and 11.1% in participants aged ≥ 65 years). According to
severity, 2.9% of adults reported a mild, 2.1% a moderate,
and 1.2% a severe tinnitus (1.0% reported that tinnitus
was a ‘big problem’ and 0.3% a ‘very big problem’). Prev-
alence of severe tinnitus was 0.8% in men and 1.6% in
women, and was 0.1% in 18–44 years participants, 1.2%
in 45–64 years, and 3.2% in ≥ 65 years. Among adults with
severe tinnitus, 2.7% were aged 18–44 and 97.3% were
aged ≥ 45 years.
Table2 shows the ORs for any, chronic and severe
tinnitus, according to selected socio-demographic char-
acteristics in the Italian population aged ≥ 45 years. Any
tinnitus increased with increasing age: as compared to
participants aged 45–54 years, the OR for those aged
≥ 75 was 4.49 (95% CI: 2.34–8.62). An inverse trend was
observed according to family income: as compared to
individuals with income <1,160 EUR/month, the OR for
those with income ≥ 1,940 EUR/month was 0.50 (95%
CI: 0.29–0.85). A higher prevalence of any tinnitus was
observed in widowed (OR: 1.88; 95% CI: 1.15–3.06) and
divorced/separated participants (OR: 2.32; 95% CI:
1.21–4.43) as compared to married participants. No sig-
nificant relation with any tinnitus was observed accord-
ing to sex and municipality size. Chronic tinnitus pat-
terns broadly reflected those of any tinnitus. Based on
the severity of the tinnitus, women more frequently re-
ported it compared to men (OR: 3.26; 95% CI: 1.28–
8.31). A significant direct trend was observed in severe
tinnitus prevalence according to age: the OR compared
to individuals aged <55 years was 9.59 (95% CI: 2.24–
40.96) for participants aged ≥ 75 years (p for trend=
0.002). Significant inverse trends were observed with
family income (p= 0.011) and municipality size (p=
0.022). No specific pattern in chronic and severe tinni-
tus was observed based on the level of education of the
participants and geographic area in which they were lo-
cated.
When compared to abstainers, the OR of any tinnitus
was 0.59 (95% CI: 0.36–0.98) for moderate and 1.38 (95%
CI: 0.87–2.21) for high alcohol drinkers ( table3 ). Corre-
sponding ORs for severe tinnitus were 0.19 (95% CI:
0.04–0.89), and 1.69 (95% CI: 0.72–3.97), respectively. A
significant direct trend was observed according to BMI
(p= 0.004): as compared to underweight and normal
weight subjects, the OR for overweight was 1.49 (95% CI:
Table 1. Percent prevalencea of tinnitus, and corresponding 95% CI, overall and by sex and age group, according to the duration of symp-
tom and its severity, among 2,952 adults, Italy, 2014
Overall Sex Age group, years
% 95% CI men women 18–44 45–64 ≥65
% 95% CI % 95% CI % 95% CI % 95% CI % 95% CI
Any tinnitus 6.2 5.3–7.0 6.0 4.7–7.2 6.4 5.2–7.6 2.7 1.8–3.6 5.9 4.5–7.4 12.3 9.9–14.6
Tinnitus duration
Acute tinnitus (<3 months) 1.3 0.9–1.7 1.1 0.5–1.6 1.6 1.0–2.2 1.4 0.7–2.1 1.3 0.6–2.1 1.2 0.4–2.0
Chronic tinnitus (≥3 months) 4.8 4.1–5.6 4.9 3.8–6.0 4.8 3.7–5.9 1.3 0.7–1.9 4.6 3.3–5.9 11.1 8.8–13.3
Tinnitus severity
Mild tinnitus 2.9 2.3–3.5 3.1 2.2–4.1 2.6 1.8–3.4 2.1 1.3–2.9 2.8 1.8–3.9 4.3 2.8–5.7
No problem 0.5 0.2–0.7 0.2 0.0–0.5 0.7 0.3–1.1 0.6 0.1–1.0 0.3 0.0–0.6 0.7 0.1–1.3
Small problem 2.4 1.8–3.0 2.9 2.0–3.8 1.9 1.2–2.6 1.5 0.8–2.2 2.6 1.6–3.6 3.6 2.3–5.0
Moderate tinnitus
Moderate problem 2.1 1.6–2.6 2.0 1.3–2.8 2.1 1.4–2.8 0.5 0.1–0.9 2.0 1.1–2.8 4.8 3.2–6.3
Severe tinnitus 1.2 0.8–1.6 0.8 0.3–1.3 1.6 1.0–2.3 0.1 0.0–0.3 1.2 0.5–1.8 3.2 1.9–4.5
Big problem 1.0 0.6–1.3 0.4 0.1–0.7 1.5 0.9–2.1 0.0 – 0.9 0.3–1.5 2.7 1.5–3.8
Very big problem 0.3 0.1–0.5 0.4 0.1–0.8 0.1 0.0–0.3 0.1 0.0–0.3 0.3 0.0–0.6 0.6 0.0–1.1
a Sometimes the sum does not add up to the total due to decimal approximations.

Gallus/Lugo/Garavello/Bosetti/Santoro/
Colombo/Perin/LaVecchia/Langguth
Neuroepidemiology
DOI: 10.1159/000431376
4
0.99–2.25) and the OR for obese 2.14 (95% CI: 1.25–3.67).
No significant relation was observed according to smok-
ing status for chronic or severe tinnitus.
Discussion
This is the first national representative study providing
data on tinnitus prevalence in the Italian adult popula-
tion. Self-reported prevalence of tinnitus was 6.2% and
that of severe tinnitus was 1.2%. The corresponding esti-
mates for adults aged ≥ 45 years were 8.7 and 2.0%, and
for the elderly (aged ≥ 65 years) 12.3 and 3.2%, respec-
tively. Only 2 previous studies, conducted more than
2decades ago, and including selected samples of the adult
population in selected areas, investigated tinnitus preva-
lence in Italy, showing substantially higher prevalence es-
timates among adults
[24, 25, 32] .
We found no sex differences in any and chronic tin-
nitus, while severe tinnitus was more frequent in women.
Table 2. Percent prevalence of any, chronic, and severe tinnitus among 1,724 adults aged ≥45 years, according to selected socio-demo-
graphic characteristics, with correspondinga OR and 95% CI, Italy, 2014
n Any tinnitus Chronic tinnitus Severe tinnitus
% OR (95% CI) % OR (95% CI) % OR (95% CI)
Total 1,724 8.7 – 7.4 – 2.0 –
Sex
Men 792 8.3 1b7.0 1b1.3 1b
Women 932 9.0 1.43 (0.92–2.20) 7.8 1.45 (0.91–2.32) 2.7 3.26 (1.28–8.31)
Age group, years
45–54 536 3.8 1b2.5 1b0.5 1b
55–64 445 8.6 2.18 (1.20–3.95) 7.1 2.63 (1.32–5.23) 2.0 3.57 (0.87–14.66)
65–74 492 10.8 2.80 (1.55–5.08) 9.9 3.79 (1.93–7.45) 2.4 4.21 (1.03–17.17)
≥75 251 15.2 4.49 (2.34–8.62) 13.4 5.87 (2.81–12.26) 4.9 9.59 (2.24–40.96)
p for trend <0.001 <0.001 0.002
Level of education
Low 934 10.1 1b8.6 1b2.6 1b
Intermediate 596 7.9 1.30 (0.85–1.99) 7.2 1.55 (0.98–2.43) 1.7 1.34 (0.59–3.04)
High 193 3.9 0.61 (0.28–1.35) 2.2 0.43 (0.16–1.19) 0.5 0.29 (0.03–2.52)
p for trend 0.727 0.788 0.587
Family income, EUR/month
I tertile (<1,160 EUR) 484 12.8 1b11.2 1b3.8 1b
II tertile (1,160–1,939 EUR) 607 9.2 0.91 (0.59–1.40) 7.8 0.88 (0.56–1.39) 2.6 1.05 (0.50–2.21)
III tertile (≥1,940 EUR) 633 5.0 0.50 (0.29–0.85) 4.1 0.49 (0.27–0.88) 0.1 0.06 (0.01–0.57)
p for trend 0.015 0.020 0.011
Marital status
Married 1,213 7.6 1b6.5 1b1.3 1b
Single 136 3.4 0.67 (0.25–1.78) 3.1 0.78 (0.28–2.15) 0.4 0.46 (0.03–6.90)
Widowed 262 15.2 1.88 (1.15–3.06) 13.3 1.86 (1.10–3.12) 5.0 2.30 (0.94–5.68)
Divorced/separated 112 11.8 2.32 (1.21–4.43) 8.4 1.85 (0.88–3.89) 5.4 5.43 (1.95–15.10)
Geographic area
Northern Italy 814 8.1 1b7.3 1b2.2 1b
Central Italy 350 6.7 0.90 (0.54–1.50) 4.9 0.69 (0.39–1.23) 0.5 0.22 (0.05–1.08)
Southern Italy/Islands 560 10.8 1.45 (0.96–2.18) 9.1 1.33 (0.86–2.05) 2.8 1.51 (0.73–3.16)
Municipality size
≤10,000 inhabitants 535 10.9 1b10.1 1b4.2 1b
10,001–50,000 inhabitants 657 7.8 0.75 (0.49–1.14) 6.7 0.68 (0.43–1.06) 0.9 0.24 (0.09–0.63)
>50,000 inhabitants 532 7.5 0.80 (0.50–1.26) 5.5 0.63 (0.38–1.05) 1.3 0.44 (0.18–1.11)
p for trend 0.282 0.054 0.022
a ORs were estimated using unconditional multiple logistic regression models after adjustment for sex, age, level of education, geo-
graphic area, smoking status, alcohol drinking, and body mass index; breference category.

Prevalence of Tinnitus in Italy Neuroepidemiology
DOI: 10.1159/000431376
5
Inconsistent results have been reported according to sex
differences. In fact, most previous studies, but not all
[10,
20] , showed higher tinnitus prevalence in men than in
women
[5, 14, 19, 36] .
A direct and steady relationship between age and prev-
alence of tinnitus was observed in the present as in other
studies
[19, 21] , suggesting that tinnitus is a symptom pe-
culiar of the elderly. Some studies, however, observed a
plateau of tinnitus prevalence around 60–70 years, and a
subsequent decline in older age groups
[9, 10, 12] .
Low socioeconomic status has been reported as a po-
tential risk factor for tinnitus in various studies
[9, 10, 16,
36] . We confirmed this observation, showing a consistent
and significant inverse relation with income, whose mag-
nitude was significantly stronger for severe tinnitus rath-
er than for any tinnitus. Accordingly, our data are com-
patible with higher (severe) tinnitus rates among resi-
dents in municipalities with a relatively small population
size. This is in agreement with a survey from China,
showing a higher tinnitus prevalence in rural than in ur-
ban areas
[18] , although in Egypt the opposite was ob-
served
[22] . A few studies investigated the relationship
between marital status and tinnitus, showing no signifi-
cant difference
[21, 36] . Conversely, we found that di-
vorced or separated participants had more frequently
any, and, in particular, severe tinnitus than married ones.
Both low income [37] and divorce/loss of partner [38] are
likely to be associated with high stress and anxiety, which
in turn have been strongly correlated with tinnitus
[39] .
Lower income could also correlate with different expo-
sure to environmental noises
[40] and consequent hear-
ing loss, which is thought to be an essential triggering
factor in tinnitus onset
[4] .
We found no significant difference in tinnitus preva-
lence according to smoking status, confirming findings
from most other studies
[17, 20, 21, 36] . Only a few sur-
veys reported a higher prevalence of tinnitus in current
than in never smokers
[9, 10] .
As regards alcohol consumption, moderate drinkers
showed the lowest tinnitus prevalence. This is consistent
with a study from Norway showing a 10 to 15% reduction
of tinnitus prevalence in moderate alcohol consumers
[9] ,
and with a US study showing a substantial reduction of
tinnitus prevalence in female alcohol drinkers
[41] . The
observed relation with alcohol reminds to the well-known
J-shaped risk curve between alcohol and the risk of myo-
cardial infarction or other cardiovascular diseases
[42–
44] . Indeed a few studies showed that tinnitus and cardio-
vascular diseases share several risk factors
[10, 41] , sup-
porting the hypothesis that a healthy microvascular
system in the inner ear
[41] , cochlear nerve [45] and cen-
tral auditory system (which is responsible for tinnitus
Table 3. Percent prevalence of any, chronic and severe tinnitus among 1,724 adults aged ≥45 years, according to smoking status, alcohol
consumption, and BMI, and correspondinga OR and 95% CI, Italy, 2014
n Any tinnitus Chronic tinnitus Severe tinnitus
% OR (95% CI) % OR (95% CI) % OR (95% CI)
Smoking status
Never smokers 1,097 8.4 1b7.2 1b2.1 1b
Current smokers 312 5.2 0.64 (0.34–1.20) 3.8 0.59 (0.29–1.19) 1.1 0.94 (0.29–3.09)
Ex-smokers 314 13.0 1.50 (0.96–2.34) 11.7 1.53 (0.96–2.46) 2.6 1.51 (0.61–3.76)
Alcohol drinking
Non-drinkers 727 9.7 1b8.5 1b2.8 1b
<7 drinks/week 483 5.0 0.59 (0.36–0.98) 4.4 0.60 (0.35–1.03) 0.4 0.19 (0.04–0.89)
≥7 drinks/week 500 10.7 1.38 (0.87–2.21) 8.8 1.29 (0.78–2.14) 2.6 1.69 (0.72–3.97)
p for trend 0.307 0.479 0.447
BMI categoriesc
Under/normal weight (BMI <25 kg/m2) 741 6.1 1b5.0 1b1.4 1b
Overweight (25≤ BMI <30 kg/m2) 642 10.5 1.49 (0.99–2.25) 9.1 1.56 (1.00–2.44) 3.2 1.99 (0.91–4.39)
Obesity (BMI ≥30 kg/m2) 175 14.7 2.14 (1.25–3.67) 13.3 2.31 (1.30–4.10) 2.7 1.50 (0.48–4.75)
p for trend 0.004 0.003 0.241
a ORs were estimated using unconditional multiple logistic regression models after adjustment for sex, age, level of education, geo-
graphic area, smoking status, alcohol drinking, and BMI; breference category; cthe sum does not add up to the total because of some
missing values.

Gallus/Lugo/Garavello/Bosetti/Santoro/
Colombo/Perin/LaVecchia/Langguth
Neuroepidemiology
DOI: 10.1159/000431376
6
chronicization) [4] may reduce the risk of tinnitus. Other
studies, however, did not find any relation between alco-
hol drinking and risk of tinnitus
[17, 20, 21, 36] .
Prevalence of any and chronic, but not severe, tinnitus
was highest among obese compared to normal weight
subjects. High BMI was reported as a possible risk factor
for tinnitus
[9] , but most studies showed no consistent
relation with overweight/obesity
[10, 17, 20, 21, 36] .
We observed one of the lowest prevalence estimates of
tinnitus (any or severe) worldwide (online suppl. table1).
Our tinnitus prevalence was similar only to those observed
in Japan
[17] , E g y p t [22] , a n d I r a n [19] , but appreciably
lower than those found in North America
[10] , A u s t r a l i a
[12] , N o r t h e r n E u r o p e [5, 14, 16] , a n d K o r e a [20, 21] . C o m -
parisons between different surveys are difficult to make,
due to the heterogeneity in terms of age range of the popu-
lation studied and the lack of a standard and validated def-
inition of tinnitus
[17, 21, 36] . W e d e c i d e d t o u s e t h e d e f i n i -
tion of tinnitus adopted in the NHANES study
[35] , w h i c h
assessed the presence of tinnitus over the past 12 months
and not only at the time of interview. This assessment tool
may therefore have led to an overestimation of current tin-
nitus prevalence. Comparisons are also complicated be-
cause of the difference in the demographic structure of var-
ious populations. The large worldwide heterogeneity in the
prevalence of tinnitus may be related to different lifestyles,
including dietary, habits
[46] . T h e M e d i t e r r a n e a n d i e t ,
characterized by a high monounsaturated/saturated fat ra-
tio, a relatively high consumption of cereals, legumes, fruit
and vegetables, and fish, a moderate consumption of alco-
hol, and a low consumption of meat and meat products, and
milk and dairy products, has been shown to reduce obesity
[47] , a n d p r e v e n t c a r d i o v a s c u l a r [48, 49] , c a n c e r [50] , a n d
overall mortality and morbidity
[51, 52] . I n I t a l y , t h e l e v e l
of adherence to the Mediterranean diet is still relatively high
[53] . A l s o h a b i t u a l d i e t s o f E g y p t , I r a n , a n d J a p a n ( i . e . t h e
other countries with relatively low rates of tinnitus) have
been shown to share some characteristics of a Mediterra-
nean-like dietary pattern
[54] . I t i s p o s s i b l e t h a t s o m e a s -
pects of the Mediterranean diet may, at least partially, pre-
vent tinnitus. This hypothesis is corroborated by our find-
ings of a favorable effect of moderate alcohol consumption
and of an unfavorable effect of obesity on tinnitus. These
results should however be confirmed by analytical epide-
miological studies, including case-control and cohort stud-
ies, providing data on incident cases
[1, 10] . D i f f e r e n c e s i n
genetic susceptibility to hearing loss and in the levels of ex-
posure to noise or chemical-induced hearing loss
[55] may
also have a role in the heterogeneity of tinnitus prevalence
estimates observed in various countries.
This is the largest study on tinnitus prevalence in Italy
and the first one conducted on a representative sample at
the national level. Our sample size was satisfactorily large
to derive stable estimates on a relatively frequent condi-
tion as any tinnitus and to assess differences in tinnitus
prevalence between various subpopulations using a mul-
tivariate analysis, after allowance for several covariates.
However, given the rarity of severe tinnitus (1.2%), the
statistical power of our sample is inappropriate to observe
differences among those with severe tinnitus (n= 36) in
terms of individual-level characteristics. Moreover, a
shortcoming that was present in all population surveys
was that information on tinnitus was self-reported, due
to the difficulties to objectively detect/diagnose tinnitus.
Other potential limitations were those inherent to the
cross-sectional design, where it was not possible to estab-
lish the mechanisms by which tinnitus and its identified
correlates mutually interact
[56, 57] .
In conclusion, in Italy tinnitus affected more than
3million adults, and severely impaired the quality of life
of more than 600,000 Italian adults, mostly aged 45 years
or more. Our data also showed that socioeconomic and
anthropometric characteristics, and selected lifestyle hab-
its may have a role on tinnitus prevalence. Our data add-
ed relevant knowledge on a condition for which inappro-
priate data on aetiologic factors and no treatments are
available today
[1, 2] .
Acknowledgements and Funding
We thank Mr. Ottorino Savani of the Italian Association of
Tinnitus (AIT-Onlus) for his contribution in the understanding of
tinnitus in Italy. The survey was conducted with the contribution
of the Italian Ministry of Health. The authors declare that there are
no conflicts of interest.
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