Most smokers now know that smoking is addictive and causes heart, lung and other diseases, but few have any idea that one of the first problems they can develop is the so-called 'smoker's droop'.
Impotence affects millions of men. Although too often a hidden problem, it is estimated that at least one in 10 men over the age of 21 suffers from impotence.
Impotence, defined as the repeated inability to have or maintain an erection, affects - for example - an estimated two million British men between 21 and 75. A 1998 study showed that 38 percent of Thai men aged 40 to 70 years were impotent, which if extrapolated to the whole nation indicated that three million Thai men have the problem. Nineteen percent of those surveyed had mild problems, 14 percent moderate and five percent severe. Yet only two percent have sought medical treatment. The incidence goes up with age: half of all men over 40 have some erection difficulties - and smokers are twice as likely to be among them.
In 1996 the American Council on Science and Health noted: "Few people are aware that smoking affects a man's reproductive, sexual and urinary organs." British men are also mostly unaware of the connection. According to a 1999 MORI poll, 88 percent of smokers in Britain over 15 years of age don't know that smoking causes impotence. When asked: 'What could lead to male impotence?' 38 percent said, 'anxiety/stress/depression,' 29 percent said 'alcohol,' but only 12 percent said 'smoking'. Even when prompted with a list of possible causes, only a third cited smoking.
Yet doctors have known for more than a decade that the seductive-looking rebel with a cigarette dangling from his lips could be on his way to problems with his sex life. Despite the industry portraying smoking as macho and glamorous, underneath it all, the rugged model may not be so virile after all. Studies from around the world - France, Sweden, South Africa, Thailand and the USA - have all confirmed the link between smoking and impotence. Overall, studies have concluded that smoking doubles the risk of becoming impotent. Smoking also compounds other risk factors such as diabetes, high cholesterol levels and drugs used to treat high blood pressure. It is calculated to be responsible for impotence in 120 000 men aged in their thirties and forties in the UK alone. The damage smoking causes is cumulative. Teenage smokers who can't kick the habit could be impotent by the time they reach their thirties or forties. Heavier smoking also increases the risk.
Research from the human laboratory confirms clinical observation: one study showed erotic films to men aged 18 to 44 years, and measured the diameter of their penises. Smoking two high-nicotine cigarettes in immediate succession significantly decreased the rate of penile diameter change. It is not just the diameter - new research shows that smokers, on average, have shorter erect penises than comparable non-smokers. Smoking also increases the risk of impotence in older patients after radiation treatment for prostate cancer. None of the men who smoked at the time of treatment were sexually potent six years after treatment. In contrast, 66 percent of the men who never smoked said they could still have an erection. For comparative purposes, 78 percent of a group of men of the same age who did not have prostate cancer could still have erections.
Impotence is now emerging as a possible early warning of heart disease developing about a decade later. The same process of narrowing arteries by which smoking causes heart disease and stroke is responsible for impotence. In a sense, the penis is like a canary in a coal mine. Because it is more sensitive to the effects of tobacco, it can provide a warning before more serious - if not fatal - consequences occur.
Therefore, not only does smoking reduce life expectancy, but it also affects the quality of life. Smokers with impotence often suffer in silence with the knowledge that the condition was totally preventable. Men's erection difficulties can be a very real problem for women too. Women often reach their sexual peak at a later age than men do, by which time the cumulative effects of smoking can have started to affect their men's ability to get or maintain an erection. This can cause distress, and problems within a relationship.
How does this happen?
Smoking has multiple effects on male sexuality: smoking decreases sperm production, deforms sperm, changes the ability of sperm to move, reduces the volume of ejaculate, and seriously reduces blood flow to the penis by restricting the flow of blood and causing long-term damage to blood vessels, clogging up the blood supply. The British Impotence Association says that blood flow to the penis can be reduced by more than 30 percent after just two cigarettes. Male smokers also have lower levels of testosterone four and higher levels of follicle stimulating hormone five (a feminising hormone) than do male non-smokers.
There are several other mechanisms whereby smoking influences erections.
A 1998 study reported in the journal Psychosomatic Medicine says impotence is nearly twice as likely in middle-aged men who have symptoms of depression than in those who don't. Depression, in turn, was found to be strongly associated with cigarette smoking, as well as low education or recent changes in marital or employment status. Just as the penis depends on good circulation, so does the clitoris. Preliminary studies show that female smokers are just as likely to have sexual problems as male smokers as they get older.
Getting the news out
Viagra, the prescription drug for impotence, has transformed male sexual dysfunction from a taboo topic to a publicly discussed health concern. The discussion surrounding Viagra has taken the issue of impotence into the public domain. And, incidentally, it was no coincidence that three of every four men who participated in the initial clinical trials for Viagra were current or former smokers.
Preachy appeals about smoking's connection to cancer, heart and lung disease may not deter young men from smoking. But they may be more inclined to quit to save their sex lives. Up to now, the smoking and impotence warning has mostly been in urologists' offices to men who had already become impotent, but the message is now spreading to far wider groups.
The state of California in the USA has been running a US$21 million anti-smoking campaign featuring a TV commercial that takes aim at smokers - directly below the belt. The story-line shows a young man's efforts at flirtation fail when special effects make his cigarette suddenly sag and dangle from his lips. "Cigarettes," says the tagline. "Still think they're sexy?" To drive home the point, another head-turning woman at the party walks past three men, each of whom is smoking. One by one, their cigarettes turn flaccid as she passes. The ads are aimed at getting through the message to a tough audience that smoking just isn't sexy.
In an almost karmic completion of a cycle, under the terms of the American multistate tobacco settlement, in 1999 Philip Morris had to hand over a huge 20-metre billboard site on Sunset Boulevard, Los Angeles, to the California Department of Health Services. The billboard had been occupied by a giant Marlboro cowboy for 16 years, but was immediately replaced with a cowboy with a flaccid cigarette, bearing the caption 'Smoking causes impotence.' In Thailand, where 90 percent of all smokers are male, cigarette packs were required to start carrying a warning from 1998: 'Cigarette smoking causes sexual impotence.' This is a message that must be in striking white letters on a black background covering one-third of each pack. The Thai health warning prompted a torrent of queries to health authorities, mostly from worried women married to smokers. The warning appeared to have had far more impact than earlier warnings like 'Smoking causes lung cancer,' or 'Smoking endangers unborn babies,' Health professionals wryly noted that Thai males seem more concerned about impotence than lung cancer.
Other countries are also calling for such warnings. They believe that if more men understood the possible damage to their sex lives, they would give up smoking. Clive Bates, director of ASH (Action on Smoking and Health), in the UK, said: "We reckon there are lots of men who would prefer to give up smoking rather than lose something as precious as their erection. But it appears that most smokers are unaware of the risk and that's why we think new warnings are needed." In the past, some public health advocates were concerned about the approach, and felt the focus should be on the 'Big Killers'. But with the decline in cigarette consumption levelling off in many countries, health groups have been searching for new ways to convince smokers to quit. They feel that this message could be particularly compelling to adolescent boys, who are concerned about sexuality and not necessarily worried about their mortality decades down the road.
Cigarette makers, who have devoted huge sums to strengthen smoking's macho, sexy image, are keeping quiet on the subject. The Wall Street Journal reported a spokesman for RJ Reynolds tobacco unit as saying: "We don't have anybody who has done any work in that area. That's about all we've got to say about it." A spokesman for Philip Morris declined to comment. A spokesman for British American Tobacco told the Times of London in 1999: "These allegations are not new. There have been two major studies of smoking and impotence and neither found a convincing relationship. As for putting a warning on cigarette packets, I think it would be potentially misleading and would trivialise the existing warnings. Mentioning impotence on the packs would detract from the fact that other more serious diseases are related to smoking."
A spokesman for smokers' rights group FOREST in Britain, with scant regard for the distressing plight of smokers and their partners, told the BBC: "The one sure way to ruin your sex life is by becoming an anti-smoking bore."
Can erections return?
Here is the good news: impotence can be reversed. Relate, the British Counselling Service, summarises that 66 percent of clients with erection difficulties report improvement after counselling. And smoking is the most preventable cause of impotence. So, if smokers quit early enough, some of the damage can be reversible. Doctors can't predict exactly how much harm can be undone when any one individual smoker quits, but it is known that some of the ill-effects of tobacco on the penis can disappear within just a few days, while others such as arterial hardening of the arteries take some time to reverse. When doctors inform patients of this lesser-known side effect of smoking, they are generally not so much surprised as remorseful. They say "If I'd only known that years ago." But it can be surprisingly difficult to convince all smokers actually suffering from impotence to quit. Harris M. Nagler, chairman of the urology department at Beth Israel Medical Centre in New York, says he has been advising impotent patients to quit smoking since the early 1980s - with little success. "The younger ones who are just beginning to have problems tend to be more inclined to stop, but I haven't been impressed by the numbers who have walked away from smoking because of it," he says. "This is truly an addiction. By Dr Judith Mackay, Director, Asian Consultancy on Tobacco Control. Senior policy advisor, WHO