Health: Bad for the Bone

The only people on earth who don’t know that smoking causes cancer are tobacco executives and the handful of isolated Amazon tribes still lost even to National Geographic photographers. We can assume, then, that when the most recent National Health Interview Survey found that 24 million adult men in the U.S. smoke, it also found 24 million adult men who know smoking can kill them. Obviously this knowledge has not motivated them to quit.

Death itself does not scare these men. So what fearsome weapon can health professionals now wield to conquer the modern scourge of smoking, among men at least? Only one thing may be more important to a man than his very life–yes, his penis.

Conveniently, two studies published last year prove the long-suspected link between smoking and impotence. One study shows a 50 percent increase in impotence among smokers under the age of 50, and the other shows a 700 percent increase when smoking is combined with heart disease. If that doesn’t do it, we might as well start stuffing Marlboro samples into Power Rangers boxes.

The link between smoking and impotence has been well-known for years among health professionals–just as anyone who’d ever seen a smoker cough hard enough to expel vital organs could make the connection between cigarettes and lung cancer long before there was a Surgeon General’s warning. In fact, the smoking-impotence link has been “talked about for 20 or 30 years,” says David Mannino of the National Center for Environmental Health in Atlanta. Still, it wasn’t until Mannino’s study last year that smoking was finally proven to be an independent cause of impotence.

The smoking-impotence link wasn’t confirmed until now because, incredibly, no one had bothered to do a population-based study of impotence before. Earlier impotence studies looked at men who attended impotency clinics, or other small groups not representative of the general population. Then, in a medical demonstration of the feast or famine cliche, last year saw the publication of both Mannino’s work and another study linking impotence to smoking headed by John B. McKinlay, director of the New England Research Institutes.

“For something that’s so important to the quality of life for men, and their partners, it’s really amazing that it hasn’t been studied,” says McKinlay, sounding bewildered.

In a way, even Mannino’s study was an accident. He used data from a 1985-’86 survey of 4,500 Vietnam veterans, and says it was a “fluke” that the veterans were even asked about impotence.The veterans who smoked reported a 3.7 percent incidence of impotence, compared to 2.2 percent of nonsmokers and 2 percent of former smokers. That’s an 80 percent increase in impotence for smokers. After controlling for other impotence risk factors, many of which are related to smoking itself, smokers are 50 percent more likely to be impotent.

“The numbers themselves are small,” Mannino explains. “The problem of complete impotence of men in this age range, about 40, is only about three percent. But it increases with age.

“Some people would argue, well, should I worry about something that only affects three percent of men? Well, yeah, but if you were one of those men you’d be very concerned about it. I go with the estimate that [impotence] affects about 10 million men. And even that’s a soft estimate,” he says, with no pun realized, much less intended.

McKinlay’s study yielded somewhat, er, harder numbers than Mannino’s estimates. “These are the first population estimates [of impotence] actually available in the world,” McKinlay says proudly. His work is based on a 1987-’89 study of 1,709 men randomly chosen from the greater Boston area. For his own analysis, McKinlay excluded men without sexual partners. He writes that their exclusion should, if anything, skew the prevalence of impotency downward “since men without partners are likely to have a greater than normal rate of impotence.”

By age 40, says McKinlay, “about 5 percent of men are completely impotent. And that increases to about 15 percent by age 70. So there’s a threefold increase in complete impotence over those 30 years.” And when you factor in minimally and moderately impotent men, “by age 70 half of all men have some degree of impotence and 15 percent are completely impotent,” he says.

“Now this is the real exciting stuff,” says McKinlay, just warming up. ” For a man to get an erection it requires a fivefold increase in arterial blood flow. So it’s very clear you need blood for an erection. And we found that all the factors that are associated with heart disease, like blood pressure, smoking, fat, and so forth, are also associated with impotence. Now smoking is very clearly related to all levels of impotence. But if you put [smoking and heart disease] together there is a 700 percent increase in complete impotence. So the message is not just that if you’re smoking it may contribute to your impotence, but also if you have heart disease and you smoke it’s absolutely disastrous.”

How, exactly, does smoking affect potency? Given a favorable psychological frame of mind, a normal erection begins with the parasympathetic nervous system, which are nerves we can’t consciously control. These nerves release neurotransmitters that stimulate blood vessels to either relax or constrict. On the arterial side of the circulation system–the incoming blood, let’s call it–the neurotransmitters tell blood vessels that supply the penis to relax and allow more blood to enter. On the venous side–the outgoing blood–the neurotransmitters tell blood vessels leaving the penis to constrict, so less blood is allowed to leave. The result is an erection.

Tobacco smoke affects this process in many ways. First, there’s that favorable psychological frame of mind. Smokers are two-to-one more likely to be depressed–no one knows why–and depression is linked to impotence. Next, nicotine, a pharmacologic agent, may actually block the neurotransmitters’ efforts to communicate with the blood vessels, impeding the increase in incoming blood to the penis and the decrease in outgoing blood. And then there’s the blood vessels themselves. On the arterial incoming side, smokers are more likely to develop atherosclerosis, or hardening of the blood vessels. Cigarette smoke contains 4,000 different substances, says Mannino, many of which are toxins. It is these toxins that build up inside a smoker’s blood vessels. If blood vessels in the groin are affected, blood flow to the penis is reduced.

And on the venous side, says Mannino, smokers’ blood vessels are less likely to constrict and retain blood in the penis. The various toxins in tobacco smoke actually poison the smooth muscle around the blood vessels, so these blood vessels can’t constrict as well.

Surprisingly, both the Mannino and McKinlay studies found no relation between impotence and the number of cigarettes smoked per day or the number of years a man had smoked. “That may be bad news for smokers,” Mannino notes. “The news may be that cutting down isn’t enough. You have to stop altogether.”

McKinlay puts an optimistic spin on things: “The good news about this, by the way, instead of it all being pessimistic–haha, I’m a male and gotta worry about these things–is that so much of this is behavioral or life-style,” he says. “And a lot of people who’ve written on this field seem to feel impotence is an inevitable consequence of aging, so you can’t do much about it….But the good news from Dr. Mannino’s work and our study is that a great deal can be accomplished from life-style alterations.”

And what about women? “Certainly in women you don’t have that easy mark, and getting into problems like sexual desire and the entire aspects of orgasm becomes incredibly more difficult to deal with,” Mannino answers. “It probably should be looked at, since more and more women are smoking and we know it affects blood flow and hormones. It may actually affect fertility in women. But clearly I would expect that it would in some way affect sexual function in women, though it might be much more difficult to determine.”

Impotence is just the thing to scare male smokers into kicking the habit, according to Michael Eriksen, director of the Office on Smoking and Health at the Centers for Disease Control and Prevention. “We think it will provide a different type of motivation,” he says happily. Eriksen hopes Mannino’s study will be especially persuasive for teenagers. “They consider themselves relatively immortal,” he says. “So for teens and young adults, social issues tend to be more important than life and death issues. And in that context, I think the recent impotency finding is the strongest social health concern that we have today that will grab the interest of men and provide a reason to stop smoking.”

McKinlay concurs. “I think maybe heart disease, people will live with it,” he theorizes. “They’ll say, ‘Well, I’ll smoke and if I have heart disease I have heart disease.’ But if smoking also affects their ability to engage in a behavior which is so highly valued in the society, which is sexual function, it may actually be a very good health education message.”

Maybe. To quickly test this theory, we went to the one place in the city where male smokers should certainly respect scientific data: the University of Chicago. The results were not promising. All understood that smoking drastically increases their risk of lung cancer and heart disease. “Yeahyeahyeah,” most interviewees said dismissively, proving the immortal youth part by admitting that it wasn’t enough to persuade them to quit. Reactions were only slightly more varied to the news that smoking causes a 50 percent increase in impotency.

“Oh Jesus, I quit,” yelped Nicholas Krupto, who’s currently unregistered.

“I don’t smoke,” grinned recent graduate Cassidy Bowman, briefly attempting to hide his smoldering cigarette.

But most interviewees simply gave a thoughtful “hmmmm” in mid-drag.

Is the threat of impotence more persuasive than that of lung cancer? Will it make them quit?

“Sad but true, yeah,” said Krupto, giving the only affirmative answer. “I think I would.”

Senior Sebastian Braithwaite was more typical: “They can pile up all the information they want in the world, but my experience has been that nicotine’s a very addictive drug and it’s very difficult to quit. I’ve tried to quit. And simply pointing out that it’s bad for you in all these wonderful perverse ways makes absolutely no difference in the basic fact that nicotine’s a very addictive drug. A fear-inspired rhetoric, in my mind, is not the way to argue against drug addiction. Because drug addiction is not a function of the rational mind, so making arguments against an irrational problem is not the right method.”

So impotence doesn’t give him an added incentive? “I have all the incentive I need,” snorted Braithwaite. “Anyone who smokes and doesn’t have an incentive to quit is illiterate or mentally deficient.”

Graduate student Jonathan Small wasn’t worried either. “The number of people who are impotent for physical reasons is very small, so just because it’s double doesn’t necessarily mean it’s greater than one in a hundred chance anyway,” he pointed out.

“I think it’s the type of thing which, not to criticize the media,” Small said with a slight sneer, “but it’s the type of thing that would make an interesting story and I think there would be people who wouldn’t understand that the numbers are still small and they would be a little bit worried.”

Others were less philosophical. “Well, it would probably take personally experiencing it to get me to quit right away because of it, to put it bluntly,” said senior Dan Leuthner.

“I smoke more often than I have sex,” explained sophomore Daniel Lav, a young man who would give Eriksen nightmares. “So it’s something everyday as opposed to a more vague consideration.” You don’t really believe the risk of impotence will affect you? “Yeah, probably. You can write down that I think I’m young and immortal or something like that. Somebody needs to say it. Yeah, that’s fairly accurate. I never really think of smoking as having any real effects. I mean, I know it does, but dying or getting lung cancer or becoming impotent seems fairly far away.”

One interviewee asked for a definition of impotence. “Yeah, that’s frightening,” said senior Mike Pohlschmidt, after impotence was defined as a complete inability to have an erection. “But at this point, no, it wouldn’t deter me. It would not force me to quit smoking. I wouldn’t even think twice.”

Even if the threat of impotence does have the power to shock men into dropping their smokes, they have to know about it first. Mannino is pleased with the press his study picked up when it was first released–the nightly news, an appearance on the Today show, a brief article on the AP wire. Still, only one smoker interviewed at the University of Chicago had even vague knowledge of the study, so the fact that smoking can cause impotence is hardly on everyone’s tongues. For that to happen, the country would have to be blanketed with ads as frightening as the old “Smoking is Glamorous” poster, which featured the scariest of imaginable derelicts–the ueber derelict, in fact–taking a drag off a cigarette. Since the risk has been known for several years, have any ads exploited the link between smoking and impotence yet?

“No,” said Jerrie Jordan, a spokesman in the American Cancer Society’s Tobacco Control Department. She paused uncomfortably. “We had not considered that. I think we were waiting for more definite proof, studies that gave us more evidence.”

When presented with the results of Mannino’s study, Jordan remained unenthusiastic. “I don’t think [impotency] will be [used in future ad campaigns],” she said. “Right now we’re targeting a lot of our efforts on preventing children from beginning to smoke. [Impotency] will be included as one of the bad effects of smoking. We’re certainly not going to deny it, but we’re not going to build a whole campaign around it. Our mission is to prevent cancer.”

Jordan’s position, however, is contradictory. She says the American Cancer Society won’t focus on impotence because it isn’t technically cancer, but she also says, “We want to emphasize that you feel better when you don’t smoke, that you’re in better physical condition.” Surely most people consider impotency a poor physical condition. Jordan also notes that Fabio was the spokesman for 1993’s Great American Smokeout to show the “positive side of not smoking.” The ability to have sex would belong on the positive side, and who better to promote that than a sex symbol like Fabio?

The two other major sources of antismoking ads–the states of California and Massachusetts–are more openminded about impotence as an antismoking tool. Both states have tax-funded antismoking programs that include media campaigns.

“We have a joke ad, and that gets a lot of laughs around the office, but we’ve never really pursued it,” said Gregory Connolly, director of the Massachusetts tobacco control program. “Part of it is that the industry uses so much sex to sell smoking, we’re reluctant to use it. But it’s a good suggestion. We’ll think about it. I don’t know, we wrestle with the ad firm–they’d do anything to get people not to smoke–and I keep saying, ‘Well, we’re a public entity, and if we use sex to unsell the product is that inappropriate?’ So no, we haven’t hit it head-on.”

Dileep G. Bal, chief of the Cancer Control Branch in the California Department of Health Services, chuckled when asked if his department had exploited smoking’s ties to impotence. “We-e-e-e-ell, nothing that we’ve put out so far, no. I do recollect, not recently, that somebody had done it in early creative meetings. It’s the sort of issue that creative people, as you might well imagine, have a ball with. But we want to make sure that we don’t make light of what to me is a very serious issue. We have a carcinogen associated with a mortality risk, and I’d rather not make it something like a carnival. It’s very easy to laugh off, and I think the issue’s a tremendously serious one.”

But Bal soon relented. “I’m glad you brought it up, we very well could [use the smoking-impotence link in the future],” he mused. “As a matter of fact, I’ll be happy to let our agency know. Actually, the more you mention it, why not?”

California media analyst Colleen Stevens confirms that the state has considered using the threat of impotence in its antismoking ads, “but we haven’t figured out how we could get away with it yet. One of the disadvantages of using [impotence] is that we still get letters questioning whether smoking really kills people. We have toyed with the idea, and we’re still toying with it. We had jokingly done one with the word impotence written going down instead of across the page. But it’s hard to get across, it’s a complicated biomedical process.”

Stevens had a copy of Mannino’s study but hadn’t read it yet. “It’s a very tempting [subject] to want to use,” she admitted.

It appears unlikely that the Mannino and McKinlay studies will enjoy significantly more publicity. And, if University of Chicago students are any indication, millions of smokers will blithely continue a massive life-style irony: trying to make themselves feel better with a habit that will yellow their teeth, foul their breath, cause premature wrinkles, drastically increase their risk of lung cancer and heart disease, and cut short their sex lives too.

Mannino recalls an editorial in a recent British medical journal that looked at why people start smoking. “One of the reasons supposedly is because they feel socially inadequate, socially impotent was the word used in the editorial,” he says. “And I thought that was an interesting use of words. A person may be trading social impotence for the real thing.”

Art accompanying story in printed newspaper (not available in this archive): Illustration/Kurt Mitchell.