would appear that even without outright vasculopathy, a
history of smoking represents the presence of a silent vas-
cular insult that persists over time.
However, not all of the damage appears to be perma-
nent. There is currently mounting evidence that some
damage is reversible if smoking is stopped prior to mid-
dle age and is not restarted (Pourmand
et al.
, 2004; Sigh-
et al.
, 2007; Harte & Meston, 2008; Chan
et al.
Interestingly, a short smoking abstinence period of
36 hours in heavy smokers can allow for signiFcant
improvements in tumescence (Guay
et al.
, 1998; Harte &
Meston, 2012) and vascular erectile parameters (SighinolF
et al.
, 2007). Along this vein, in a cohort of 143 men with
ED who quit smoking,
50% reported improvements in
erectile function at 6 months
double the rate of those
who were unable to quit (Chan
et al.
, 2010). Effects per-
sisted for at least 1 year (Chan
et al.
, 2010). Among
patients with no other risk factors, successful smoking
cessation via an 8-week trial of nicotine replacement ther-
apy signiFcantly improved erectile function at a 1-year
follow-up (Pourmand
et al.
, 2004).
It appears, however, that age modiFes the chances of
regaining erectile function. In the study by Pourmand
et al.
(2004), improvements were conFned to patients
50 years old. Likewise, in another study by Chew
et al.
(2009), those who quit and were under 50 years of age
did not show increased risks of ED. A slightly higher age
of 60 years was shown by Austoni
et al.
(2005) to delin-
eate better ORs for former smokers compared to current
smokers of similar ages.
±urthermore, the severity of a patient’s ED may also pre-
dict one’s response to quitting. In the study by Pourmand
et al.
(2004), of those men who regained erectile function
after quitting smoking, 49% had only mild ED at baseline.
No men with severe ED regained function
a worrisome
statistic as many former smokers are more likely to have
severe ED (Chew
et al.
, 2009). The presence of other vas-
cular risk factors such as hypertension or diabetes further
increased the odds of ED in former smokers. ±urthermore,
men with these comorbidities did not show beneFts to
quitting smoking, suggesting that smoking may not pres-
ent an additional vascular risk if vascular damage from
hypertension, hyperlipidaemia, diabetes and cardiovascular
disease is already present (Austoni
et al.
, 2005).
In summary, large epidemiologic studies do not appear
to show a return to baseline risk in men who are
smokers. Smaller studies, however, do show that younger
men (
50 years old) have a better chance of erectile
improvement after quitting. Early cessation is necessary
to increase the chances of erectile improvement. There
also appears to be a physiologic set point where the pres-
ence of severe cardiovascular disease and ED does not
respond to smoking cessation.
In the general population, over half of men over the age
of 40 will have some varying degree of ED. Smokers are
at even higher risk of developing ED independent of age
and comorbidities. There is overwhelming evidence in the
literature to support the claim that smoking worsens
erectile function through vascular mechanisms (primarily
depletion of nitric oxide). It is yet unclear whether, at a
population level, quitting smoking will improve ED rates;
however, in controlled trials, gains in erectile function are
made by men who do. Unfortunately, the current litera-
ture suggests that this improvement is limited to younger
men with a more minor smoking history and a lack of
JRK and RR are NIH K12 Scholars supported by a Male
Reproductive Health Research Career (MHRH) Develop-
ment Physician-Scientist Award (HD073917-01) from the
Eunice Kennedy Shriver National Institute of Child
Health and Human Development (NICHD) Program.
Austoni EMV, Parazzini ±, ±asolo CB, Turchi P, Pescatori ES,
Ricci E, Gentile V (2005) Andrology prevention week
centres; Italian Society of Andrology.
Eur Urol
Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser
DB, Rimm EB (2006) A prospective study of risk factors for
erectile dysfunction.
J Urol
Burnett AL (1995) Nitric oxide control of lower genitourinary
tract functions: a review.
Butler R, Morris AD, Struthers AD (2001) Cigarette smoking
in men and vascular responsiveness.
Br J Clin Pharmacol
Cao S, Yin X, Wang Y, Zhou H, Song ±, Lu Z (2013)
Smoking and risk of erectile dysfunction: systematic review
of observational studies with meta-analysis.
PLoS One
Celermajer DS, Sorensen KE, Georgakopoulos D, Bull C,
Thomas O, Robinson J, DeanFeld JE (1993) Cigarette
smoking is associated with dose-related and potentially
reversible impairment of endothelium-dependent dilation in
healthy young adults.
Chan SS, Leung DY, Abdullah AS, Lo SS, Yip AW, Kok WM,
Ho SY, Lam TH (2010) Smoking-cessation and adherence
intervention among Chinese patients with erectile
Am J Prev Med
2014 Blackwell Verlag GmbH
, 1087–1092
Smoking and male erectile function
J. R. Kovac
et al.