Association of Smoking with Erectile Dysfunction

Almost all 20% of middle-aged men in America are active smokers and Cigarette smoking is a leading cause of preventable morbidity and mortality in the United States. 

In addition to the well-established harmful effects of smoking (i.e coronary artery disease and lung cancer), the past three decades have evidence being compiled into the development of a relationship between cigarette smoking and erectile dysfunction

Today let’s discuss How and Why smoking causes Erectile Dysfunction?

Association of smoking with Erectile Dysfunction

The process of Erection is dependent on the parasympathetic nervous system, which induces smooth muscle relaxation allowing arterial pressure blood into the muscles of the penis via the actions of nitric oxide (NO).

Nitric Oxide is generated by three nitric oxide synthase (NOS) enzyme isoforms: neuronal, endothelial, and inducible. The Neuronal nitric oxide and Endothelial nitric oxide are the primary mediators of physiologic erection.

As mentioned above, the most well-understood mechanism underlying ED involves the Nitric Oxide pathway. Both constituent nitric oxide synthase isoforms, the endothelial and neuronal variants, have been shown to be affected by cigarette smoke. Neuronal nitric oxide synthase activity by non-adrenergic non-cholinergic neurons is known to be decreased in men who smoke. Components of burned, but not unburned tobacco, are in part responsible for the loss of neuronal Nitric Oxide through the enzymatic blockade.

Furthermore, in addition to cigarettes’ effect on the enzymatic synthesis, superoxide anions produced by the metabolites from smoke directly decrease the level of free Nitric Oxide in the muscles of the Penis. Superoxide anions are increased in smokers and their presence shunts NO into a peroxynitrite pathway that lessens the vasoactive availability of Nitric Oxide. 

The Rho-associated kinase (ROK), which regulates sensitivity to calcium contractility in the smooth muscle cell, is known to maintain the flaccid state and, as such, Rho-associated kinase-inhibitors can be theorized to induce erection. Intracellular Nitric Oxide functions to inhibit Rho-associated kinase allowing for vasodilation. Similarly, decreases in Nitric Oxide levels secondary to smoking, disinhibit Rho-associated kinase, and act to further worsen ED. Furthermore, smokers have decreased Rho-associated kinase activity in peripheral leukocytes correlating to poor nitroglycerin vasodilation further hinting at a connection between Rho-associated kinase signaling and smoking.

Dose dependency of Erectile Dysfunction

Cigarette smoking has been suggested to act with dose-dependency as a risk factor for heart disease as well as ED. In a subgroup analysis of other larger studies, odds ratios of patients who developed ED showed a significant difference when men smoked greater than 10 cigarettes per day.

In a younger, less comorbid population, heavy smokers (>20 cigarettes/day) had doubled the likelihood of severe ED compared to those who smoked less.

Overall, it appears that the cumulative dose of cigarette exposure does predict the odds of developing ED. Examining the severity of the ED, current evidence appears to suggest that heavy smoking causes more severe ED that appears to be not reversible following smoking cessation.

Effects of smoking cessation on Erectile Dysfunction

In some studies, Former smokers (defined as having quit smoking >1 year prior to the study), have an increased risk of suffering from any form of ED compared to men who have never smoked. Former smokers have also been shown to have increased risk compared to current smokers, even when adjusted for age.

However, not all of the damage appears to be permanent. There is currently mounting evidence that some damage is reversible if smoking is stopped prior to middle age and is not restarted.


The Erectile Dysfunction caused by smoking can be treated by oral medications and other treatment methods available. Consulting a doctor surely helps erectile dysfunction caused by smoking. Many men are reluctant to discuss erectile dysfunction with their doctors. But don’t let embarrassment keep you from getting help. Just taking this step will get them on their way to recover not only their sex life but their relationship as well. They need not worry about their privacy as clinics like “The ED Clinic”  take full care to make sure all privacy details are just that- Private.

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