The Wall Street Journal -- November 9, 1998
How Impotence
Became Weapon
Against Smoking
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By Suein L. Hwang and Nick Cumming-Bruce
Staff Reporters of The Wall Street Journal
A potent new weapon is surfacing in the battle against smoking: impotence.
Scientists have known about links between smoking and sexual problems for several years. But doctors and health-advocacy groups -- in some cases emboldened by the global publicity for the drug Viagra -- are just now beginning to trumpet the warnings.
The state of California has been been running a $21 million antismoking campaign featuring a TV commercial in which a man's efforts at flirtation fail when his cigarette goes limp. "Cigarettes," says the tagline. "Still think they're sexy?"
Last week in Thailand, where 90% of all smokers are male, cigarette packs were required to start carrying this warning: "Cigarette smoking causes sexual impotence." That message, one of a series of tough warnings to be printed in rotation, must be plastered in white letters on a black background covering one-third of each pack.
Last night, CBS television's "60 Minutes" dedicated a segment to the problem, featuring prominent doctors warning that smokers have a greater likelihood of suffering impotence.
The spate of attention has caused a buzz among public health groups. After being away from his office in Washington for two weeks, one leading activist, Matthew Myers, returned to find roughly 20 e-mails sent by various activists interested in the approach. As executive vice president of the Campaign for Tobacco-Free Kids, he says, "It could have a powerful impact."
Tobacco's role in cancer and cardiovascular disease has been the antismoking message of choice for years. To the extent the impotence warning surfaced, it has mostly been in urologists' offices, where patients have been warned to avoid cigarettes for nearly two decades.
Now publicity for Pfizer Inc.'s Viagra, the prescription drug for impotence, has transformed male sexual dysfunction from a taboo topic to a publicly discussed health concern. "Absent the Viagra debate, impotence wasn't a commonly discussed topic," says Carla Agar, deputy director of the California Department of Health Services in Sacramento. "I think the discussion surrounding Viagra has allowed us to take the issue of impotence into the public domain." Ms. Agar says her department has heard little criticism of the ad since its launch last summer.
For decades, doctors have believed smoking can harm a man's sexual function because it constricts blood vessels, compromising blood flow. Over the years, studies have strengthened those beliefs, most recently in 1994, when a study published in the American Journal of Epidemiology surveyed Vietnam veterans and found that while 2.2% of nonsmokers suffered persistent impotence, 3.7% of current smokers did. Many researchers also believe that smoking may lower sperm count as well.
"Smoking is a significant cause of impotence, there's no question about that," said a spokesman for Pfizer, who adds that 75% of the men in Viagra's clinical trials were current or former smokers.
Cigarette makers, who have devoted huge sums to strengthen smoking's macho, sexy image, are mum on the subject. "We don't have anybody who has done any work in that area," a spokesman for RJR Nabisco Holdings Corp.'s Reynolds tobacco unit says. "That's about all we've got to say about it." A spokesman for Philip Morris Cos. declined to comment.
In the past, some public health advocates were concerned about the approach. "The focus has always been on the big killers, so there may be some feeling this is a distraction," says antitobacco activist Michael Pertschuk, former head of the Federal Trade Commission. "The only time we've talked about it is half in jest, and that's part of the problem. Sexual impotence can quickly degenerate into parody."
But with the decline in the nation's cigarette consumption leveling off, health groups have been searching for new ways to convince smokers to quit. This message could be particularly compelling to adolescent boys, who are concerned about sexuality and not necessarily worried about their mortality decades down the road.
There is anecdotal evidence that the method has worked in Thailand. Adulvit Kitchakarn, deputy secretary general of the Thai Tobacco Monopoly, traveled to northern Thailand 30 years ago to investigate rumors that menthol cigarettes caused penile shrinkage. The locals were suffering from nothing worse than chilly winter weather, he concluded, but menthol cigarette sales dropped for months.
"If men are not concerned about their heart or their lungs, maybe they will be concerned about their sex life," chuckles Prakit Vathirsathojkit, secretary-general of the National Committee for Control of Tobacco Use, who provided the impetus for the Thai package warning, believed to the first in the world.
Other Asian countries -- which have half the world's smokers -- are watching the Thai program closely, according to Dr. Judith MacKay of the Hong-Kong based Asian Consultancy on Tobacco Control. "I only have to mention impotence to an audience and everyone sits up," she says. "We're saying maybe the Marlboro cowboy isn't so virile after all."
Drawing heavily on a post-lunch cigarette outside a central Bangkok McDonald's, 62-year-old Chalerm Am-prasit is wholly unimpressed. A veteran smoker of 43 years, he limits himself to a pack a day for financial reasons only. "I won't stop smoking for any doctor," he says, brushing aside any talk of impotence.
Bodin Sanarin, a 25-year-old bartender in Bangkok's notorious Patpong red-light zone, is similarly nonchalant. "I read the cautions on every single packet. I believe they're true," he says. But he says he hasn't noticed any sexual problem personally, so his early fears have subsided.
That is a major hurdle for public-health groups trying to use the impotence message: Only a small percentage of smokers ultimately wind up with a serious problem, says Kenneth Laughery, a psychology professor at Rice University who has conducted research on the effectiveness of warning labels. "There's an 'It won't happen to me' kind of phenomenon," he says.
That's the message Massachusetts health officials got when they showed California's sagging-cigarette ad to focus groups. "It was humorous, but it wasn't believable," says Gregory Connelly, director of the Massachusetts Department of Public Health. "They think of personal examples where it's not true." Instead, Massachusetts runs highly personal ads of ailing smokers, including a series focusing on the travails of a young mother with emphysema.
It can even be difficult to convince smokers actually suffering from impotence to quit. Harris M. Nagler, chairman of the urology department at Beth Israel Medical Center in New York, says he has been advising impotent patients to quit smoking since the early 1980s -- with little success. "The younger ones who are just beginning to have problems tend to be more inclined to stop, but I haven't been impressed by the numbers who have walked away from smoking because of it," he says. "This is truly an addiction."
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