The effect of alcohol drinking on erectile dysfunction in Chinese men

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Abstract

Erectile dysfunction (ED), smoking, and alcohol drinking are common in middle-aged men. Although smoking has been shown to be a risk factor of ED in Chinese and other populations, the relationship between drinking alcohol and ED is not clear. The Family Planning Association of Hong Kong conducted the Men Health Survey in 2004. In all, 1506 men aged 20–70 years were recruited by stratified random sampling of the male population. Face-to-face interviews were used to collect information on drinking and smoking and other life style factors, morbidities, and sociodemographic status during household visits. The more sensitive information on sexual activity and ED was obtained by a self-completed questionnaire at the end of the interview. A total of 816 subjects aged 31–60 years currently active in sexual activity were included in the present analysis. Compared with never drinkers, alcohol drinkers who consumed three or more standard drinks (one standard drink equals 12 g of alcohol) a week were more likely to report EDs as defined by having both sexual dissatisfaction and erectile difficulty (odds ratio (OR)=2.27, 95% confidence interval (CI)=1.28–4.03) after adjusting for age and cigarette smoking. When analyzed separately by smoking habit, the risks were higher in current smokers (OR=2.27, 95% CI=1.01–5.11) than never smokers (OR=1.91, 95% CI=0.68–5.35). Our results suggest that alcohol drinking of three or more standard drinks per week might reduce sexual satisfaction and impair erectile function in current smokers and might have less effect in never smokers.

Introduction

Erectile dysfunction (ED) or impotence is defined as ‘the inability to attain and/or maintain an erection satisfactorily for sexual intercourse.’1 ED may compromise life satisfaction among men, affecting their self-esteem, relationships, and job performance.2 ED is a common problem among older men.3 There is strong evidence that ED shares a similar pathogenesis with other forms of vascular diseases.4 Behavioral risks with ED included obesity,5 smoking,6 sedentary lifestyle,7 and alcohol drinking.8 Among various behavioral risks, the role of alcohol in ED has been the most controversial.

Alcohol is the leading cause of disability in developed countries and the fourth leading cause of disability for men in the developing countries.9 It is associated with several cardiovascular risks such as hypertension and hyperlipidemia,10 metabolic syndrome,11 and prostate or urinary problems.12 The relationship between alcohol drinking and ED remained inconsistent in earlier studies.13, 14 Only two studies examined such relationship among Chinese subjects,15, 16 but the results were also indefinite. Even alcohol drinking and smoking are concurrent habits for many subjects, the effect of alcohol intake on ED among smokers has been infrequently addressed.

Drinking alcohol is popular and growing steadily in Hong Kong. The relationship between ED and alcohol intake among Hong Kong men is not known and earlier data elsewhere are inconsistent. This study aimed to study the relationship between alcohol drinking and ED among Hong Kong men taking into account smoking status in a population based cross-sectional study.

Materials and methods

Details of the Methods were reported elsewhere,6 and are described briefly below.

Study design

The Family Planning Association of Hong Kong conducted the Men Health Survey in 2001, and the use of the data was approved by the internal review board of the association. In all, 1506 men aged 20–70 years were recruited by stratified random sampling of the male population. Face-to-face interviews were used during household visits to collect information on drinking and smoking and other life style factors, morbidities, and sociodemographic status. The more sensitive information on sexual activity and ED was obtained by an anonymous self-completed questionnaire at the end of the interview.

The questionnaire

The questionnaire asked for information on: (1) demographics and others: age, marital status, education level, financial status, and regular medication; (2) drinking habit: frequency of drinking in a week and the usual amount of liquor that they most often drank every time; for ex-drinkers, only those quitted longer than 12 months were included in the present analysis; (3) smoking habit: number of cigarettes smoked per day; current smokers were further divided into those who smoked <20 cigarettes per day or 20 cigarettes per day; (4) sex practice: number of sexual partners was assessed with the question ‘How many sexual partners did you have within the last 6 months?’ Satisfaction during sexual intercourse was assessed with the question ‘For your sex life in the past 6 months, did you feel satisfied during sexual intercourse?’ Erection difficulty in sexual intercourse was assessed with the question ‘For your sex life in the past 6 months, did you have any difficulty in maintaining erection throughout the entire process of sexual intercourse?’ We derived these two questions from the definition of ED, ‘the inability to attain and maintain an erection satisfactory for sexual intercourse.’1

Reliability and internal validity of the study tool were obtained in a pilot study. A panel consisted of a professor in public health and epidemiology, a consultant urologist, an experienced statistician, researchers, and Family Planning Association of Hong Kong staff were responsible for assuring the face and content validity of the questionnaire. Feasibility and sensitivity issues to probe sex practice of adult men were carefully addressed to facilitate participation and minimize embarrassment by protecting anonymity of participants.6

Analysis

We included only subjects aged 31–60 years who were currently active in sexual activity because few subjects aged below 31 years had ED, and older subjects had much less sexual activity. Current drinkers were those who claimed to have drinking habit. The amount of alcohol intake was measured by the number of standard drinks per week. One standard drink was defined as 12 g of alcohol. The risks, in terms of odds ratios (ORs) with 95% confidence intervals (CIs), of dissatisfaction with sexual intercourse, difficulty in maintaining erection, and ED due to drinking were estimated by logistic regression with the adjustment of age in 5 years because the raw data collected were in the 5-year age groups. A P-value of <0.05 was considered statistically significant (two-tailed).

Results

A total of 2049 living quarters were initially sampled for the survey. In all, 1941 households were approached for interview and 1506 men (one from each household) were successfully interviewed. The response rate was 77.6%. We included only subjects aged 31–60 years. The duration of quitting smoking and/or drinking may have effects on ED, so those who quit for <1 year (3 ex-drinkers, 13 ex-smokers) were excluded. Further excluded were those without any sexual partners (n=87), leaving 816 subjects in the present analysis.

Table 1 shows that 23.6% were aged 51–60 years, 91.2% of the subjects were married, 14.1% attained tertiary education level, 36.1% were current drinkers, and 38.2% were current smokers. Table 1 also gives the prevalence of sexual dissatisfaction and erection difficulty. Overall, 19.8% were dissatisfied with sexual intercourse, 36.3% had erection difficulty, but only 11.1% reported having dissatisfied sexual intercourse and erection difficulty at the same time.

Table 1 Characteristics and prevalence of sexual dissatisfaction and erection difficulty of 816 men in the Hong Kong Men Health Survey

Table 2 shows that 40.0% were light smokers (<20 cigarettes per day) and 52.9% heavy smokers (20 cigarettes per day) were current drinkers. The discrepancy in smoking habit in terms of number of cigarettes per day was small among current drinkers (21.0% vs 28.1%), and about 50% of current drinkers were current smokers.

Table 2 Prevalence of alcohol drinking status by smoking statusa

There was a higher risk in all categories of sexual functioning, reflected by having OR of >1 among current drinkers who consumed three or more standard drinks per week (Table 3). Compared with never drinkers, the effect of drinking on dissatisfaction of sexual intercourse (OR=1.69, 95% CI=1.06–2.71) and ED (OR=2.27, 95% CI=1.28–4.03) was significantly higher among those who drank three or more standard drinks (one standard drink equals 12 g of alcohol) per week after adjusting for age and amount of cigarette smoking. Subgroup analysis of current smokers also gave significant OR for the effect of drinking (OR=2.27, 95% CI=1.01–5.11) among those who consumed three or more standard drinks in a week compared with never drinkers. Of special interest, the significant ORs were only those of dissatisfaction during sexual intercourse, as a separate or as a composite variable, and not of erection difficulty per se.

Table 3 Adjusted odds ratios (ORs)a of sexual dissatisfaction, erection difficulty by smoking, and drinking statusb

Discussion

Our results suggest that alcohol drinking showed either a threshold relationship or a J-shaped relationship with ED, as defined by having both sexual dissatisfaction and erection difficulty, with drinking amount, that is, never drinkers as reference, OR=0.73 for those who consumed not more than one standard drink per week, OR=0.93 for two standard drinks per week, and OR=2.27 for three or more standard drinks per week. This is consistent with other studies in which an increased risk of ED was only associated with a higher amount of alcohol intake in terms of grams of alcohol (<20 g per day as reference, OR=0.56 for 20–40 g per day, OR=1.29 for 40 g per day),17 or in terms of glasses of alcoholic beverages (non-drinkers as reference, OR=1 for 3 glasses daily, OR=1.4 for >3 glasses daily),18 and heavy drinkers (non-drinkers or <3 times per week as reference, OR=0.91 for 3–4 times per week, OR=1.36 for >4 times per week).19 However, we were unable to distinguish between the two kinds of relationship because of insufficient sample size in the different categories of drinking amount. The same patterns were also observed in the subgroup analyses by smoking status, and the relationship was clearer in current smokers than never smokers.

A comparison of the results of our study with Mak's study revealed an important difference in the threshold level of drinking amount.17 In Mak's study,17 a lower risk of ED was associated with 20–40 g of alcohol per day, that is, about 11–23 standard drinks per week, which was found to have an increased risk of ED in our study. This suggests that the threshold level, if any, of drinking amount can vary from population to population. Such a variation may be due to the fact that those men who consumed ‘small’ amount of alcohol beverages were more health conscious, and hence were related to a lower risk of ED, but how to define ‘small’ amount is culture specific. In a low drinking prevalence community like Hong Kong, the lowest risk was found at consumption of not more than two standard drinks per week, but in the West where drinking is common, for example in Belgium, it was 11–23 standard drinks per week. In other words, the threshold or J-shaped relationship may be explained by the existence of a group of more health conscious men who drank only a ‘small’ amount of alcohol beverages.

The effect of alcohol drinking is controversial in both cross-sectional and prospective studies. Drinking was not found to be related to ED in two cross-sectional studies,16, 20 but other cross-sectional studies reported that drinking might be associated with an increased risk of ED.21, 22 The meta-analysis of 11 cross-sectional studies by Cheng et al.14 showed a significant protective effect of alcohol, but the effect of drinking in these studies were not homogenous. Of the 11 studies reviewed, three studies showed that drinking might increase or decrease the risk of ED,15, 17, 19 depending on the amount or duration of drinking. For example, Bai et al.15 examined the relationship among Chinese men, and showed that drinking habit could be protective against ED, but chronic drinking (>20 years) could be a risk. The association between drinking and ED was also found to be inconsistent in prospective studies.5, 13, 23 One of the possible explanations for the unclear effect of drinking on ED may be due to the J-shaped relationship. For example, if there are equal proportion of light drinkers and heavy drinkers in the population, the comparison of drinkers (light and heavy) and non-drinkers may results in null effect. On the other hand, if there are only a few heavy drinkers in the population, the comparison of drinkers and non-drinkers may show that drinking is associated with a lower risk of ED.

About 40% of our men had difficulty in erection, suggesting that ED is a common public health issue that may directly affect the quality of life of the male population.2 At the same time, having both smoking and drinking habits was also common. Half of the drinkers also smoked. Although smoking is a known risk factor of ED in Chinese men6, 15 and other populations,8, 24 the effect of concurrent drinking and smoking on ED remains unclear. Cigarette smoking in the analyses did not seem to incur increased odds of ED as all ORs for smoking were not statistically significant. However, subgroup analysis of never drinkers showed that those who smoked 20 cigarettes daily were more likely to have difficulty in erection than never smokers (OR=1.98, 95% CI=1.10–3.58) (table not shown). As the drinking effect might be due to residual confounding of smoking, subgroup analysis of never-smokers and current smokers was done. The analysis of the risk of ED showed that the risk from drinking was lower in never smokers (OR=1.13) than in current smokers (OR=1.71). Our findings are in line with that from a cross-sectional study21 and a case–control study,25 as they suggested that alcohol drinking may aggravate ED.

Limitations

First, the cross-sectional design of our study limited the strength of evidence for a causal relationship between alcohol and ED. Reversed causality might be possible as men with ED might resort to more drinking as a means of escape. However, because some people with ED might have quit drinking, the association we observed could have been underestimated.

Second, the sample size in our study was limited. For example, the number of never smokers that is required to detect a significant OR of 1.91 for three or more standard drinks with 80% power and 5% significance is 1912, and hence the statistical power was low (only about 25%). As a result, the statistically significant ORs may be due to the problem of multiple comparisons, and should be interpreted with caution. As drinking becomes popular among Chinese people,26 further studies with a bigger sample size are needed.

Third, sexual satisfaction and functioning are known to be linked with other psychosocial factors like depression,27 spousal relationship,15 or lifestyle factors such as obesity,13 physical activity,28 testosterone levels, lipids, medications, blood pressure, diabetes, and cardiovascular conditions, thus adjustment of these factors are warranted in future studies.

Fourth, the data on ED were based on the participants’ responses to the two questions. As an investigative instrument for ED, the question on maintaining erection might be oversimplistic and did not take into account of the quality of the erection or the man's confidence in getting and keeping it. Asking if the responder felt satisfied during sexual intercourse was to assess his level of satisfaction and not whether the activity had been satisfactory. So the comparison of the present findings with those from other studies assessed with International Index of Erectile Function questionnaire, might be limited. Moreover, because ED was dichotomized in the present analysis, the severity of ED in relation to drinking could not be examined.

Fifth, another problem was the definition and measurement of alcohol intake to make meaningful comparison between study results. Some studies used drinking habit (yes/no), others measured the intake in terms of glasses (for example 1–4 glasses per day, drank 20–40 g per day), and our study used the number of standard drinks in a week (for example not more than one standard drink in a week). The accurate measurement of alcohol intake is a major problem, because we only assessed the usual amount that they most often drank every time, rather than the amounts of different kinds of drinks that they drank every time, and we also did not know the duration of their drinking habit.

Conclusions

Our results suggest that in Hong Kong where alcohol drinking is much lower than in the West, alcohol drinking of three or more standard drinks (that is 36 g) per week might reduce sexual satisfaction and affect erectile function in current smokers and might have less effect in never smokers. The lower risk of ED associated with small amount of alcohol beverages might be due to the inclusion of more health conscious men in this category.

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Acknowledgements

We thank all the members of the Men's Health Survey Steering Committee, the Family Planning Association of Hong Kong, and the participants of the study.

Author information

Correspondence to T H Lam.

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The authors declare no conflict of interest.

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Lee, A., Ho, L., Yip, A. et al. The effect of alcohol drinking on erectile dysfunction in Chinese men. Int J Impot Res 22, 272–278 (2010) doi:10.1038/ijir.2010.15

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Keywords

  • sexual satisfaction
  • erectile dysfunction
  • alcohol drinking
  • smoking
  • Chinese

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