Study Implicates E-Cigarette Use in ED

A recent study suggests what urologists and men's sexual health experts have suspected for years: The use of e-cigarettes, or vaping, is associated with erectile dysfunction (ED). Tobacco use has long been linked to ED, however, research has been lacking for vaping because it's a relatively new phenomenon, particularly among young men.

Daily users of electronic nicotine delivery systems (ENDS) are more than two times more likely to report ED than men who have never used e-cigarettes, according to a 2021 population-based study conducted by researchers from NYU Grossman School of Medicine in New York City and Johns Hopkins University School of Medicine in Baltimore. The study looked at survey data from nearly 14,000 men.

"Given that many people use e-cigarettes as a form of smoking harm reduction or to help them quit smoking, we need to fully investigate the relationship between vaping products and erectile dysfunction, and thus better understand the potential implications for men's sexual health," said Omar El Shahawy, M.D., Ph.D., an assistant professor in the population health department at NYU Langone Health and the study's lead author, in a press release.

E-cigarette use appears to be associated with ED independent of age, cardiovascular disease and other common risk factors.

"Our findings underscore the need to study patterns of e-cigarette use that are relatively safer than smoking," he continued. "Our analyses accounted for the cigarette smoking history of participants, including those who were never cigarette smokers to begin with, so it is possible that daily e-cigarette vaping may be associated with higher odds of erectile dysfunction regardless of one's smoking history."

E-cigarette use appears to be associated with ED independent of age, cardiovascular disease and other common risk factors, according to the researchers, who noted vapers should be informed about the potential link between e-cigarettes and ED.

Researchers drew on data from the Population Assessment of Tobacco and Health (PATH) national survey, which examines tobacco use behaviors and health outcomes. The study included 13,711 men ages 20 and older who responded to a question about ED. A large majority of these men were ages 20 to 65 with no history of heart disease.

The study found a significant association between e-cigarette use and ED among respondents with normal body mass index (BMI) and without cardiovascular disease, suggesting the association exists even among a relatively healthy population.

Limitations to the study included using self-reported data, which is prone to bias, and a lack of data on whether the respondents were taking any ED medications.

Urologists react to the study's findings

The study's finding of an association between vaping and ED did not surprise Martin Kathrins, M.D., an assistant professor of surgery at Harvard Medical School and a urologist at Brigham and Women's Hospital in Boston. Kathrins said he expects this study to be the "tip of the iceberg" in forthcoming literature that looks critically at e-cigarette use and erectile dysfunction.

"Just because these things are associated doesn't necessarily mean they're causative, because it's a retrospective study," Kathrins said. "[But] it definitely should give people pause who are interested in sexual health and vaping."

Neel Parekh, M.D., a clinical assistant professor of urology at the Cleveland Clinic, also was not surprised by the study's results and called the research a step in the right direction.

"It's something we've had a strong suspicion for," he said. "We're going to continue to potentially see the long-term effects of vaping. I'm sure more long-term studies will be coming out looking at the effect on erections."

Next steps in the research

El Shahawy said in the press release that the next phase is to gain more understanding of whether particular types of electronic nicotine delivery systems have a stronger association with ED than others. He said researchers also want to investigate whether ED is reversible once users quit vaping.

Moving forward, animal studies may be the best way to study causation, explained Seth Cohen, M.D., an assistant professor of urology and director of sexual medicine at NYU Langone Health in New York City. Researchers can dissect animals and examine the damage to the system of tiny blood vessels known as the microvasculature.

"What you're interested in is what does their body look like five years after they started, 10 years after they started, 20 years after they started, so you can see damage within the arteries of their fingers and toes and heart and coronaries and, of course, the penile vessels," Cohen said. "But how are you supposed to do that if someone is still alive?"

Cohen said looking for certain chemical markers for inflammation, such as C-reactive protein (CRP), or using a penile duplex Doppler ultrasound (PDDU) to examine blood flow within the vessels may be future options.

However, he suspects researchers may not see major findings in young people because of their exceptional healing abilities.

"Kids in their teens and 20s, even 30s, heal up so well that you may not see things until chronic smoking after 10 to 15 years," Cohen said. "With animal models, researchers can speed up the process and subject them to different doses and strengths."

A controlled setting is a big advantage to researchers, during and after experiments. During an autopsy, researchers can measure blood vessel diameter and look for plaque locations and see if they're changing.

Kathrins said he does not know if vaping is as harmful as traditional cigarettes to erections because more clinical trials are needed. He acknowledged this research will be difficult to do because fewer people are smoking, which is great in the grand scheme.

"To say that we're going to have an absolutely controlled trial where you're matching patient characteristics for smokers versus vapers versus controls, I don't know, that might be wishful thinking," he said. "But that's the kind of data you want."