For all the transitory fashions in approaches about how best to motivate smokers to quit, studies of ex-smokers and attempting quitters repeatedly affirm that the primary motivation for stopping smoking remains concern about health consequences—both in the future and those already being experienced.¹ Despite folklore about youth being indifferent about their future health, there is evidence that health concerns motivate cessation among young smokers^2,3 as well as in older smokers closer to slipping off life’s mortal coil.⁴ There is typically daylight between smokers’ nomination of health concerns and all other motivations like cost, social unacceptability and concerns about being smelly. This understanding and the mounting evidence that scare campaigns cause quitline meltdown⁵ and precipitate cessation⁶ has seen a global renaissance in efforts to worry smokers about the consequences of basting one’s lungs with tobacco smoke—some 87 000 times a year if you are a 20 a day, 12 puff per cigarette smoker.⁷

GRIM WARNINGS

Barely an organ or function of the body escapes the cornucopia of horrors that smoking causes. Grim prime-time TV ads and graphic pack warnings have shown smokers what gangrene from peripheral vascular disease looks like (although scratch and sniff “educational” cards impregnated with the unforgettable odours of putrescene or cadaverine have yet to surface). Tobacco industry advertising positioning smoking as being about discernment, judgement and elegance has had to compete with pictures from autopsy showing what a brain haemorrhage during a stroke looks like.⁸ A surgical gloved hand squeezing gelatinous atheroma from a smoker’s aorta⁸ has disturbed the complacent ambiance of countless smokers’ living rooms in the over 30 countries now using the Australian “Every cigarette is doing you damage” campaign.

Clinical reports of associations between smoking and erectile dysfunction have been around now for some years. In 2000, these reports were given strong support by a cohort study showing a near doubling in the incidence of impotence in smokers.⁹ Impotency warnings are appearing on some nations’ graphic pack warnings. My favourite is the disconsolate Brazilian couple contemplating a long night after the debonair male’s wedding tackle failed to fire (fig 1).

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Figure 1

 Brazilian health warning: “Smoking causes sexual impotence”

In this issue, a large cross sectional study from Australia¹⁰ shows that the adjusted odds ratio of a 40–49 year old smoker having prolonged erectile problems compared to a non-smoker is 3.50, rising to 5.96 for smokers aged 50–59 years. With one in 10 of all men in the study reporting prolonged erectile problems and the manufacturers of impotency treatments cashing in on the anxiety this causes, sexual impotency plainly has enormous potential to bring a new saliency to the health and personal consequences of smoking.

IMPOTENCE MESSAGE

However, some within the tobacco control fraternity are circumspect about the enthusiasm for impotence warning messages. Their argument runs that because impotence is uncommon in younger men, and that widespread advertising for campaigns for impotency therapies construct impotence as a fate awaiting middle and older aged men, that young smokers will greet such messages with incredulity and discount any concern because of its distant threat. This scepticism may even spill over to other warnings. They see the impotence message as alas lending titillating, prurient and possibly a trivialising edge to what they believe ought to be a more “deadly” message. Focus group testing of candidate messages for the recent introduction of graphic pack warnings in Australia saw an impotency warning discarded after those interviewed suggested the warning was unbelievable and “easily laughed off”.¹¹ However, such a reaction may well have reflected a group dynamics issue in the context of the research setting, with men being ill at ease in admitting concern about erectile problems in front of other men. So is this pessimism reasonable?

Such criticisms can of course also be levelled at all health focused messages because age is the single biggest predictor of the onset of disease and far fewer young compared to older smokers have had personal experience of such outcomes. Like all chronic disease caused and aggravated by smoking, erectile dysfunction is not an acute effect of smoking, but a consequence that develops from years of vascular assault.

Importantly, Doll et al’s 50 year follow up of their British male doctor cohort reminds us that “those who stopped before middle age [age 40]… had a pattern of survival similar to that of men who had never smoked”.¹² Cardiovascular damage from smoking can reverse with smoking cessation and early signs of impotency, generating the distress it can, may act as a powerful motivator for life saving cessation in middle aged men.

Even the most corpulent tobacco control campaign budgets pale into insignificance alongside those for mainstream consumer goods. Experienced tobacco control campaigners understand well that controversial, conversation-generating health advertising can often generate far greater exposure via associated news coverage and media debate than the ads themselves.^13,14

The impotency issue also holds potential to subvert decades of tobacco industry cultivation of smoking as a symbol of male potency. If widespread publicity came to forge a natural apposition between the cigarette and a vision of a flaccid dejected penis, the semiotics of smoking may change radically.