Smoking cessation for erection resurrection

Dear Dr. G,

I am a 25-year-old who regrettably started smoking when I was 17, and I have been having problems when I really should be at the peak of my sex life in my mid-twenties.

It began after the pandemic, when I started noticing that I hardly have any morning erections compared to when I was younger.

Things have gotten worse since then, as my erection is sub-optimal most of the time.

I have been to see doctors, who have said that I have erectile dysfunction and reckoned that smoking is the main culprit.

Having heard this, I am somewhat skeptical when it comes to the link between erectile dysfunction and smoking. Don’t get me wrong, I am convinced that it is a filthy habit – but I am not sure of the real impact of cigarettes on sexual function.

As such, I am putting Dr G on the spot for clarification. Can erectile dysfunction really affect men in their 20s and can quitting smoking bring back my erection?

Yours truly,

Resurrection Richard

Malaysia’s National Health and Morbidity Survey 2019 shows that when Malaysian adult men were asked about their erection in bed, three in 10 admitted having difficulties. More alarmingly, nearly 37% of the participants having erectile dysfunction (ED) were men aged between 18 and 29. A similar study of 790 participants in an Italian clinic seeking help for new-onset sexual dysfunction showed that one in four men presenting with new-onset ED were less than 40 years old.

Additionally, approximately half of the men that were under 40-years-old presented with severe ED. Both studies in Malaysia and Italy show that erectile dysfunction is not just affecting older men.

Cigarette smoking is a leading cause of preventable morbidity and mortality. The same Survey of Health and Morbidity in 2019 also revealed that 21% of participants admitted to regular cigarette smoking, and 1 in 2 reported having been exposed to second-hand smoke at home and public spaces. Although public policies have resulted in a decreased number of new smokers, smoking rates remain stubbornly high worldwide. In addition to the well-established harmful effects of smoking such as coronary artery disease and lung cancer, evidence is also being compiled into the development of a mechanism and relationship between cigarette smoking and erectile dysfunction.

The penile erectile tissues are specialised spongy vascular structures encapsulated by an envelope of penile covering and an erection requires the adequate relaxation of smooth muscles and dilation of vasculatures allowing inflow and the subsequent trapping of blood to sustain erectile rigidity. The most well understood signal transduction mechanism underlying erection involves nerves and the nitric oxide pathway. It has been well-established that cigarette smoke damages the nerves and impairs the nitric oxide-mediated vascular relaxation required for erection.

In the Male Health Professionals Study, of the 22,086 men without baseline ED, the relative risk that smokers developed ED over a follow up of 14 years was 40%. A recent systematic review which compiled eight case-control and cohort studies composed of 28,586 men has an even higher risk of smokers developing erectile dysfunction; it is as high as 80%.

Cigarette smoking has also been suggested to act with dose-dependency as a risk-factor for erectile dysfunction. Heavy young smokers who smoke more than 20 cigarettes per day have doubled the likelihood of severe erectile dysfunction compared to those who smoked less.

Although large epidemiologic studies do not appear to show a return to baseline risk in men who are smokers, smaller studies do show that younger men below the age of 50 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 presence of severe cardiovascular disease and ED does not respond to smoking cessation, but there is also evidence that some damage is reversible if smoking is stopped prior to middle age and is not restarted.

Interestingly, a short smoking abstinence period of 24–36 hours in heavy smokers can allow for significant improvements in their erection as a study with 143 men with ED who quit smoking showed that more than 50% reported improvements in erectile function at 6 months, which is double the rate of those who were unable to quit.

Another study showed that amongst patients with no other risk factors, successful smoking cessation via an eight-week trial of nicotine replacement therapy has significantly improved erectile function at a one year follow-up.

When Dr G is put on the spot by men who contemplate the cessation of smoking as New Year Resolution for the resurrection of the erection, his view is that a resolution to resurrect should be more important than any other, before it’s too late. On that note, whatever the resurrection, let’s make it a good one for all.

Happy New Year!