International Journal of Impotence Research (2010) 22, 272–278
& 2010 Macmillan Publishers Limited All rights reserved 0955-9930/10
www.nature.com/ijir
ORIGINAL ARTICLE
The effect of alcohol drinking on erectile dysfunction in
Chinese men
ACK Lee1, LM Ho2, AWC Yip3, S Fan4 and TH Lam2
1
Department of Nursing Studies, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
Department of Community Medicine, School of Public Health, Li Ka Shing Faculty of Medicine, The University of
Hong Kong, Hong Kong, China; 3Department of Surgery, Kwong Wah Hospital, Hong Kong, China and 4The Family
Planning Association of Hong Kong, Hong Kong, China
2
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) ¼ 2.27, 95% confidence
interval (CI) ¼ 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 ¼ 2.27, 95% CI ¼ 1.01–5.11) than
never smokers (OR ¼ 1.91, 95% CI ¼ 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.
International Journal of Impotence Research (2010) 22, 272–278; doi:10.1038/ijir.2010.15;
published online 17 June 2010
Keywords: sexual satisfaction; erectile dysfunction; alcohol drinking; smoking; Chinese
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
Correspondence: Professor TH Lam, Department of
Community Medicine, School of Public Health, Li Ka
Shing Faculty of Medicine, The University of Hong Kong;
5/F William MW Mong Building, 21, Sassoon Road,
Pokfulam, Hong Kong SAR, China.
E-mail: [email protected]
Received 1 March 2010; revised 10 May 2010; accepted 22
May 2010; published online 17 June 2010
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
Effect of alcohol drinking on erectile dysfunction in Chinese men
ACK Lee et al
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 o20 cigarettes per
day or X20 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
273
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 o0.05 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 o1 year (3 ex-drinkers,
13 ex-smokers) were excluded. Further excluded
were those without any sexual partners (n ¼ 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 2 shows that 40.0% were light smokers
(o20 cigarettes per day) and 52.9% heavy smokers
(X20 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.
There was a higher risk in all categories of
sexual functioning, reflected by having OR of 41
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 ¼ 1.69,
International Journal of Impotence Research
Effect of alcohol drinking on erectile dysfunction in Chinese men
ACK Lee et al
274
Table 1 Characteristics and prevalence of sexual dissatisfaction and erection difficulty of 816 men in the Hong Kong Men Health Survey
Characteristics of
study sample
Prevalence of sexual Prevalence of difficulty Prevalence of erectile
in erection (B) b
dysfunction (A and B) c
dissatisfaction (A) a
N
%
Age (years)
31–35
36–40
41–45
46–50
51–55
55–60
114
202
164
143
120
73
14.0
24.8
20.1
17.5
14.7
8.9
12.2
18.3
18.8
26.3
18.6
27.7
24.1
31.1
32.9
43.6
43.1
52.2
1.9
10.7
11.0
16.0
12.4
15.9
Marital status
Married
Single
Other
744
63
9
91.2
7.7
1.1
19.1
25.0
37.5
36.6
35.0
12.5
10.9
13.3
12.5
Education
Primary or below
Secondary
Matriculation
Tertiary
160
495
46
115
19.6
60.7
5.6
14.1
18.2
20.9
19.6
17.1
40.8
37.9
28.9
26.1
9.9
12.2
15.6
6.3
Personal income US$1 ¼ HK$7.80
Less than HK$10 000
HK$10 000–19 999
HK$20 000 or more
192
358
209
25.3
47.2
27.5
23.8
20.4
15.7
45.9
34.4
26.6
14.4
10.8
7.6
Alcohol drinking habit
Never drinker
Ex-drinker
Current drinkerd
p1 standard drink per week
2 standard drinks per week
X3 standard drinks per week
456
65
295
35
102
156
56.0
8.0
36.1
4.3
12.5
19.2
17.7
16.4
23.7
18.2
21.3
26.2
34.3
38.1
38.8
45.5
32.6
41.1
9.2
11.5
14.1
9.1
8.5
18.2
Smoking habit
Never smoker
Ex-smoker
Current smoker o20 cigarettes per day
Current smoker X20 cigarettes per day
391
113
155
157
47.9
13.9
19.0
19.2
19.7
13.8
18.2
25.9
33.4
41.3
33.8
42.0
10.2
11.1
9.6
15.1
Number of sex partners in the past 6 months
One
685
More than one
67
Unspecified number of sex partners
64
84.0
8.2
7.8
18.7
27.4
23.7
33.7
35.5
63.5
9.8
17.7
19.0
Regular medication on a long-term basis
No
Yes
88.0
12.0
20.5
14.3
34.7
47.8
11.1
11.2
—
19.8
36.3
11.1
Total
718
98
—
a
Dissatisfied with sexual intercourse if someone was seldom satisfied, not satisfied almost every time, or not satisfied every time.
Had erection difficulty during sexual intercourse if someone had some, great, or very great difficulty.
c
Dissatisfied with sexual intercourse and had erection difficulty during sexual intercourse.
d
Two cases did not give enough information for calculating the amount of alcohol drinking.
b
95% CI ¼ 1.06–2.71) and ED (OR ¼ 2.27, 95%
CI ¼ 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
International Journal of Impotence Research
(OR ¼ 2.27, 95% CI ¼ 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.
Effect of alcohol drinking on erectile dysfunction in Chinese men
ACK Lee et al
275
Table 2 Prevalence of alcohol drinking status by smoking statusa
Never smoker
Ex-smoker
Current smoker
(o20 cigarettes per day)
Current smoker
(X20 cigarettes per day)
Never drinker
N
Row (%)
Column (%)
271
59.4
69.3
42
9.2
37.2
82
18.0
52.9
61
13.4
38.9
Ex-drinker
N
Row (%)
Column (%)
15
23.1
3.8
26
40.0
23.0
11
16.9
7.1
13
20.0
8.3
Current drinker
N
Row (%)
Column (%)
105
35.6
26.9
45
15.3
39.8
62
21.0
40.0
83
28.1
52.9
p1 standard drink per week
Nb
Row (%)
Column (%)
19
54.3
4.9
3
8.6
2.7
3
8.6
2.0
10
28.6
6.4
2 standard drinks per week
Nb
Row (%)
Column (%)
45
44.1
11.5
16
15.7
14.2
21
20.6
13.6
20
19.6
12.8
X3 standard drinks per week
41
Nb
Row (%)
26.3
Column (%)
10.5
26
16.7
23.0
37
23.7
24.0
52
33.3
33.3
a
One standard drink equals 12 g of alcohol.
The numbers may not be added up to the total number of current drinkers because of missing data.
b
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 ¼ 0.73 for those who consumed not
more than one standard drink per week, OR ¼ 0.93
for two standard drinks per week, and OR ¼ 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 (o20 g
per day as reference, OR ¼ 0.56 for 20–40 g per day,
OR ¼ 1.29 for X40 g per day),17 or in terms of glasses
of alcoholic beverages (non-drinkers as reference,
OR ¼ 1 for p3 glasses daily, OR ¼ 1.4 for 43 glasses
daily),18 and heavy drinkers (non-drinkers or o3
times per week as reference, OR ¼ 0.91 for 3–4 times
per week, OR ¼ 1.36 for 44 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.
International Journal of Impotence Research
Effect of alcohol drinking on erectile dysfunction in Chinese men
ACK Lee et al
276
Table 3 Adjusted odds ratios (ORs)a of sexual dissatisfaction, erection difficulty by smoking, and drinking statusb
Dissatisfied with sexual
intercourse c (A)
OR
Total (n ¼ 816)
Drinking habitf
Never drinker
Ex-drinker
Current drinker
p1 standard drink per week
2 standard drinks per week
X3 standard drinks per week
95% CI
Had difficulty in
erection d (B)
OR
95% CI
1
1.05
1.43
0.82
1.31
1.69*
(0.50,
(0.97,
(0.32,
(0.74,
(1.06,
2.23)
2.11)
2.09)
2.30)
2.71)
1
1.04
1.11
1.20
0.87
1.25
(0.58,
(0.80,
(0.58,
(0.54,
(0.84,
1
0.54
0.89
1.26
(0.29, 1.02)
(0.54, 1.47)
(0.79, 2.02)
1
1.20
1.06
1.40
Never smokers (n ¼ 391)
Never drinker
Ex-drinker
Current drinker
p1 standard drink per week
2 standard drinks per week
X3 standard drinks per week
1
1.40
1.11
0.91
1.18
1.16
(0.41,
(0.61,
(0.28,
(0.51,
(0.48,
4.79)
2.03)
2.98)
2.72)
2.78)
Current smokers (n ¼ 312)
Drinking habitf
Never drinker
Ex-drinker
Current drinker
p1 standard drink per week
2 standard drinks per week
X3 standard drinks per week
1
1.52
1.42
0.35
1.03
1.74
(0.49,
(0.78,
(0.04,
(0.40,
(0.91,
1
1.50
Smoking habitg
Never smoker
Ex-smoker
Current smoker (o20 cigarettes per day)
Current smoker (X20 cigarettes per day)
Smoking habitg
Current smoker (o20 cigarettes per day)
Current smoker (X20 cigarettes per day)
Erectile dysfunction
(A and B) e
OR
95% CI
1
1.33
1.54
0.73
0.93
2.27**
(0.55,
(0.94,
(0.21,
(0.42,
(1.28,
(0.76, 1.92)
(0.70, 1.60)
(0.93, 2.11)
1
0.85
0.93
1.39
(0.41, 1.74)
(0.48, 1.81)
(0.77, 2.52)
1
0.66
1.28
1.44
1.39
1.10
(0.20,
(0.77,
(0.53,
(0.69,
(0.53,
2.23)
2.11)
3.89)
2.80)
2.28)
1
2.21
1.13
0.83
0.71
1.91
(0.55,
(0.51,
(0.17,
(0.20,
(0.68,
4.69)
2.59)
2.93)
2.66)
3.35)
1
1.06
0.95
0.76
0.55
1.20
(0.41,
(0.57,
(0.22,
(0.24,
(0.68,
2.76)
1.59)
2.63)
1.26)
2.14)
1
1.91
1.71
—h
0.93
2.27*
(0.84, 2.68)
1
1.31
(0.80, 2.14)
1.85)
1.54)
2.50)
1.42)
1.88)
1
1.56
3.25)
2.53)
2.55)
2.09)
4.03)
8.82)
2.49)
3.93)
2.56)
5.35)
(0.47, 7.79)
(0.80, 3.69)
(0.24, 3.52)
(1.01, 5.11)
(0.74, 3.27)
Abbreviation: CI, confidence interval.
a
ORs were adjusted for age of 5 years.
b
One standard drink equals 12 g of alcohol.
c
Dissatisfied with sexual intercourse if someone was seldom satisfied, not satisfied almost every time, or not satisfied every time.
d
Had erection difficulty during sexual intercourse if someone had some, great, or very great difficulty.
e
Dissatisfied with sexual intercourse and had erection difficulty during sexual intercourse.
f
Additionally adjusted for smoking habit.
g
Additionally adjusted for drinking habit.
h
OR cannot be calculated because all those who consumed not more than one standard drink reported no erectile dysfunction.
*Po0.05; **Po0.01.
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 metaanalysis 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
International Journal of Impotence Research
Chinese men, and showed that drinking habit could
be protective against ED, but chronic drinking (420
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 nondrinkers may results in null effect. On the other
hand, if there are only a few heavy drinkers in the
Effect of alcohol drinking on erectile dysfunction in Chinese men
ACK Lee et al
population, the comparison of drinkers and nondrinkers 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 X20 cigarettes daily were more likely to
have difficulty in erection than never smokers
(OR ¼ 1.98, 95% CI ¼ 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 ¼ 1.13)
than in current smokers (OR ¼ 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.
277
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
X36 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.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
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.
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