Significance
The use of light-emitting electronic devices for reading, communication, and entertainment has greatly increased recently. We found that the use of these devices before bedtime prolongs the time it takes to fall asleep, delays the circadian clock, suppresses levels of the sleep-promoting hormone melatonin, reduces the amount and delays the timing of REM sleep, and reduces alertness the following morning. Use of light-emitting devices immediately before bedtime also increases alertness at that time, which may lead users to delay bedtime at home. Overall, we found that the use of portable light-emitting devices immediately before bedtime has biological effects that may perpetuate sleep deficiency and disrupt circadian rhythms, both of which can have adverse impacts on performance, health, and safety.
Abstract
In the past 50 y, there has been a decline in average sleep duration and quality, with adverse consequences on general health. A representative survey of 1,508 American adults recently revealed that 90% of Americans used some type of electronics at least a few nights per week within 1 h before bedtime. Mounting evidence from countries around the world shows the negative impact of such technology use on sleep. This negative impact on sleep may be due to the short-wavelength–enriched light emitted by these electronic devices, given that artificial-light exposure has been shown experimentally to produce alerting effects, suppress melatonin, and phase-shift the biological clock. A few reports have shown that these devices suppress melatonin levels, but little is known about the effects on circadian phase or the following sleep episode, exposing a substantial gap in our knowledge of how this increasingly popular technology affects sleep. Here we compare the biological effects of reading an electronic book on a light-emitting device (LE-eBook) with reading a printed book in the hours before bedtime. Participants reading an LE-eBook took longer to fall asleep and had reduced evening sleepiness, reduced melatonin secretion, later timing of their circadian clock, and reduced next-morning alertness than when reading a printed book. These results demonstrate that evening exposure to an LE-eBook phase-delays the circadian clock, acutely suppresses melatonin, and has important implications for understanding the impact of such technologies on sleep, performance, health, and safety.
The use of electronic devices for reading, communication, and entertainment has greatly increased in recent years. Greater portability, convenience, and ease of access to reading materials in electronic form add to the popularity of these devices. The use of light-emitting devices immediately before bedtime is a concern because light is the most potent environmental signal that impacts the human circadian clock and may therefore play a role in perpetuating sleep deficiency (1). The circadian-timing system synchronizes numerous internal physiological and biochemical processes, including the daily rhythm of sleep propensity (2), to external environmental time cues. For optimal sleep duration and quality, the timing of the sleep episode must be appropriately aligned with the timing of the circadian clock. In humans, exposure to light in the evening and early part of the night, even at low intensity, suppresses the release of the sleep-facilitating hormone melatonin (3–5) and shifts the circadian clock to a later time (3, 6), both of which make it more difficult to fall asleep at night. Light exposure in the biological evening/night also acutely increases alertness (7, 8), but not much is known about its impact on alertness the following day. Here we present results from a randomized study comparing the effects of reading before bedtime using a light-emitting eReader (LE-eBook) with reading a printed book by reflected light. We examined circadian timing and suppression of melatonin, polysomnographic (PSG) recordings of sleep, and subjective and objective measures of sleepiness both in the evening while reading and the following morning.
Discussion
We found that, compared with reading a printed book in reflected light, reading a LE-eBook in the hours before bedtime decreased subjective sleepiness, decreased EEG delta/theta activity, and suppressed the late evening rise of pineal melatonin secretion during the time that the book was being read. We also found that, compared with reading a printed book, reading an LE-eBook in the hours before bedtime lengthened sleep latency; delayed the phase of the endogenous circadian pacemaker that drives the timing of daily rhythms of melatonin secretion, sleep propensity, and REM sleep propensity; and impaired morning alertness. These results indicate that reading an LE-eBook in the hours before bedtime likely has unintended biological consequences that may adversely impact performance, health, and safety. The results of this study are of particular concern, given recent evidence linking chronic suppression of melatonin secretion by nocturnal light exposure with the increased risk of breast, colorectal, and advanced prostate cancer associated with night-shift work (for review, see ref. 10), which has now been classified as a probable carcinogen by the World Health Organization (11, 12). Moreover, the observation that the endogenous circadian melatonin phase was 1.5 h later when reading an LE-eBook compared with reading from a printed book suggests that using a light-emitting device in the hours before bedtime is likely to increase the risk of delayed sleep-phase disorder and sleep onset insomnia (13), especially among individuals living in society who self-select their bedtimes and wake times. Induction of such misalignment of circadian phase is likely to lead to chronic sleep deficiency (1).
The decreased sleepiness before bedtime and longer sleep latency we observed in the LE-eBook condition is likely due to both an acute alerting effect of light and a delay of the circadian timing system. Suppression of melatonin by exposure to evening light may be an underlying mechanism by which light acutely increases alertness, as seen in the present study and in previous reports (14–19). Other studies, however, have not found a relationship between alertness and melatonin levels during light exposure (20, 21) or have shown changes in alertness induced by light exposure during the day, when melatonin levels are at low or undetectable levels (22–24). The circadian-phase delay, as marked by the endogenous melatonin rhythm, probably also contributed to the delay of sleep onset that occurred after study participants were reading the LE-eBook. The significant difference in sleep latency occurred even though the scheduled bedtime was fixed at 10:00 PM each night during the study protocol to ensure an 8-h sleep opportunity in bed. Thus, these results likely underestimate the impact that use of these devices in the hours before bedtime has on self-selected sleep timing and duration.
The effects of the LE-eBook on sleepiness the following morning, however, cannot be due to the acute effects of light observed the previous evening. Individuals were sleepier the morning after reading in the LE-eBook condition than after reading a printed book the evening before; however, the light levels in the morning were identical for both reading conditions. Therefore, the difference in morning sleepiness between the conditions is most likely due to differences in the prior sleep episode and/or the circadian-phase delay. Indeed, it did take longer for participants to fall asleep after the LE-eBook condition, but there was no difference in average sleep duration and the magnitude of the difference in sleep latency is unlikely to account for the effect on alertness observed 8 h later. The difference in REM sleep between the conditions may have contributed to the difference in morning sleepiness ratings. Given that the majority of REM sleep occurs in the latter portion of the sleep episode (25) (i.e., closer to wake time), participants had significantly less REM sleep in the LE-eBook condition. Because most spontaneous awakenings occur out of REM sleep (26, 27), this reduction in REM sleep in the LE-eBook condition may have also impacted sleepiness upon awakening. The significant phase delay after the LE-eBook condition suggests that the evening light from the LE-eBook phase delayed the circadian clock, delaying the nadir of the circadian rhythm of sleep propensity (2) and thereby resulting in a robust, albeit indirect, effect on morning sleepiness. A phase delay of the circadian clock is consistent with the slower rise in the rate of accumulation of REM sleep. The change in the timing of REM sleep likely represents a delay in the circadian rhythm of REM sleep propensity, which is temporally coincident with the sleep propensity rhythm (25).
The spectral composition of the light emitted by the LE-eBook may explain why the magnitude of the melatonin-suppressing and phase-shifting response observed was greater than would be predicted for this moderately low level of light (3). In humans, exposure to short-wavelength monochromatic light in the evening has been shown to induce greater circadian and alerting responses than exposure to the same number of photons of longer-wavelength monochromatic light (17–19, 28–34), even though the shorter-wavelength light may have a much lower illuminance level when measured in photopic lux (35). For this reason, it has recently been proposed that lux is an inappropriate measure for estimation of the impact of light on melatonin suppression, circadian-phase shifting, and other non–image-forming effects of retinal light exposure (35).
This study had a number of limitations. First, melatonin suppression was assessed on the fifth and final evening of each reading condition. Although it is likely that the phase shift in the LE-eBook condition had already occurred by this time, melatonin suppression was calculated by using the shifted area under the curve (AUC) from the following evening and thus should control for any phase shift. Therefore, the greater suppression seen was not due to an effect of a delayed phase in the LE-eBook condition. Second, the duration of the evening reading sessions were 4 h long. However, given that the average teenager in the United States spends 7.5 h per day engaged in recreational media plus time spent on homework—which both occur in the late afternoon/evening, including the hour before bedtime (36), and which both involve exposure to light-emitting screens (e.g., LE eReaders, computers, televisions, tablets, smartphones, video game consoles, etc.)—the 4-h exposure interval used in this study is likely in the range of screen time exposure experienced by millions of Americans each evening. Third, in the present study, the LE-eBook was set to maximum brightness throughout the 4-h reading session, whereas, by comparison, the print-book condition consisted of reflected exposure to very dim light. However, a number of newer models of light-emitting devices are even brighter than those used in this study. Moreover, in this study, the LE-eBook reader was held at a fixed distance (30–45 cm) from the eye, further from the eye than many people might have chosen (therefore reducing retinal light exposure), particularly for users of smaller devices who may hold the smaller screens closer to the eyes. Lastly, although the short-wavelength light from the LE-eBook may have been responsible for the effects reported here, this study did not include a light-emitting device with longer wavelength for comparison, so our findings may be due to the difference in irradiance level rather than spectral composition.
This study demonstrates that use of a light-emitting electronic device in the hours before bedtime can have significant impact on sleep, alertness, and the circadian clock. The 10-min-shorter sleep latency after the print-book condition compared with sleep latency after the LE-eBook condition is similar to the effect size of eszopiclone treatment on sleep latency in patients with primary insomnia (37). Our findings provide evidence that the electric light to which we are exposed between dusk and bedtime has profound biological effects. Because technology use in the hours before bedtime is most prevalent in children and adolescents (36), physiological studies on the impact of such light exposure on both learning and development are needed. Further investigation of the physiological and medical effects of electronic devices is warranted, because the acute responses to the short-wavelength–enriched light emitted by them may have longer-term health consequences than previously considered...
Acknowledgments
We thank the study participants, the staff of the Brigham and Women’s Hospital Center for Clinical Investigation [part of the Harvard Catalyst Clinical and Translational Science Center (CTSC)], the staffs of the Division of Sleep Medicine Sleep and EEG Core and Chronobiology Core, Dayna Bradstreet for significant contributions to recruitment and conduct of the study, and Michael Herf and Robert Lucas, Ph.D. for assistance with the spectral light analysis. We also thank Wei Wang, Ph.D. for assistance with statistical analysis supported by the Harvard Catalyst CTSC [National Center for Research Resources (NCRR) and the National Center for Advancing Translational Sciences, National Institutes of Health (NIH) Award UL1 RR025758 and financial contributions from the Brigham and Women’s Hospital (BWH), Harvard University, and its other affiliated academic health care centers]. This work was supported by NIH Grant R01HL077453. The inpatient studies were conducted in the Harvard CTSC, supported by NCRR Grant UL1 RR025758. A-M.C. was supported in part by NIH Grant K01HL115458. D.A. was supported in part by the German Aerospace Center. J.F.D. was supported in part by NIH Grant R01HL094654. C.A.C. was supported in part by NASA NNX10AF47G and the National Space Biomedical Research Institute through NASA NCC 9-58.