3.6 Reproductive health

Last updated: February 2020 
Suggested citation: Hurley, S, Greenhalgh, EM & Winstanley, MH. 3.6 Reproductive health. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors].  Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from  http://www.tobaccoinaustralia.org.au/3-6-reproductive-health-and-smoking

3.6.1 Menstrual function, menarche and menopause

The US Surgeon General’s reports have examined the impact of smoking on menstrual cycles and reproductive lifespan: the period from the commencement of menstruation (menarche) to its cessation (menopause).1, 2

Women who smoke are, generally, at higher risk of dysmenorrhoea (painful menstruation) and a range of other symptoms such as premenstrual tension and heavy periods.2-4 In the US Nurses’ Health Study, for example, smokers were twice as likely as non-smokers to develop premenstrual syndrome over a two- to four-year period.5 Women who smoke are also more likely to develop its most severe form, Premenstrual Dysphoric Disorder.6 Smokers also tend to have a shorter and more variable menstrual cycle. The former has been attributed to a shortening of the follicular phase. A non-statistically significant higher risk of anovulation in smokers has been found in some studies. These effects are consistent with an increased risk of infertility (see Section 3.6.2) as the timing of ovulation is less predictable in women with variable cycle length and a shortened follicular phase may indicate abnormal formation of follicles and maturation of ova.2

Smoking may also result in an earlier menopause. A meta-analysis found that smokers were between 0.8 to 1.7 years younger than non-smokers at menopause,2 and several major population-based studies have similarly found that smokers reach menopause significantly earlier than never smokers.7-10 The relationship appears to be dose-response in nature, such that the highest risk of early natural menopause is observed among current heavy smokers.11 More menopausal symptoms have also been reported among women who smoke, such as night sweats and hot flushes.2, 12-15 It has been suggested that shorter cycles may deplete oocytes earlier leading to an earlier menopause and thus a shorter reproductive life span. An earlier age at menarche has been reported for the daughters of women who smoked heavily during pregnancy.2

3.6.2 Fertility

Measures of fertility include fecundability (the monthly probability of conception), infertility (defined as lack of conception after one year of unprotected intercourse), and sub-fertility (reduced fertility, measured by time to conception or inability to conceive within six months). Smoking reduces fertility in women. Studies have found reduced pregnancy rates, longer time to pregnancy and decreased fecundability in women who smoke.2, 7, 16-18 A recent review concluded that smoking compromises nearly every system involved in the reproductive process.19 A trend of decreased fertility with increasing number of cigarettes smoked has been reported.20 The American Society for Reproductive Medicine estimated that 13% of infertility may be attributable to smoking. Impaired fertility has been attributed to the polycyclic aromatic hydrocarbons in cigarette smoke and diminished oviductal functioning.2

In relation to the impact of male smoking on sperm quality and fertility, the 2004 US Surgeon General’s report concluded that although the evidence suggests that smoking may decrease semen volume and sperm number, and increase the number of abnormal forms present, it was insufficient to establish causality.21 The 2010 report found strengthened evidence for decreased semen quality and fertility associated with exposure to tobacco smoke either in utero or in adulthood. The report found consistent evidence linking smoking to chromosome changes or DNA damage in sperm, adversely affecting male fertility and pregnancy viability as well as anomalies in offspring.2 A large number of more recent studies and reviews have similarly found associations between smoking and decreased sperm quality and sperm DNA damage.22-42

3.6.3 Assisted reproduction (see 3.15.5 Treatment of infertility)

3.6.4 Sexual function

The link between smoking and erectile dysfunction (ED; defined as the persistent inability to attain and maintain penile erection adequate for satisfactory sexual performance) has been studied extensively.43 The 2014 US Surgeon General’s report concluded that smoking causes ED,44 and several more recent reviews further support this conclusion.45, 46 Vasospasm induced by the nicotine in cigarette smoke has been suggested as a mechanism for the acute deleterious effects of smoking on erectile function, while the chronic effects are caused by impaired vascular physiology of the erectile tissue. The Surgeon General has recommended promoting non-smoking to prevent ED, and cessation to limit the risk of ED.44

A study of about 130 Italian women found that smokers have decreased blood flow to genital blood vessels, which may impair sexual function.47 While some studies have found no relationship between smoking and sexual function among women,48 others have found smoking to be an independent risk factor for female sexual dysfunction (recurrent or persistent deficiency in sexual desire and arousal, difficulty or absence of reaching orgasm, and genital pain) in a dose-response manner (i.e., the higher the pack-years, the greater the dysfunction).49 An Australian study found that smoking was associated with sexual difficulties in both men and women. For women, even light smoking was associated with not finding sex pleasurable and being unable to orgasm.50

3.6.5 Sexually transmitted diseases (see 3.9.7 Infections of reproductive organs)


Relevant news and research

For recent news items and research on this topic, click here.(Last updated May 2021)


References for Section 3.6

1. US Department of Health and Human Services. Women and smoking. A report of the US Surgeon General, Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001/index.htm.

2. US Department of Health and Human Services. How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease. A report of the US Surgeon General, Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. Available from: http://www.surgeongeneral.gov/library/tobaccosmoke/report/index.html.

3. Jenabi E, Khazaei SP, and Veisani YP. The relationship between smoking and dysmenorrhea: A meta-analysis. Women and Health, 2019; 59(5):524-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30481133

4. Ju H, Jones M, and Mishra GD. Smoking and trajectories of dysmenorrhoea among young Australian women. Tobacco Control, 2016; 25(2):195-202. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25403655

5. Bertone-Johnson ER, Hankinson SE, Johnson SR, and Manson JE. Cigarette smoking and the development of premenstrual syndrome. American Journal of Epidemiology, 2008; 168(8):938-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18701443

6. Fernandez MDM, Montes-Martinez A, Pineiro-Lamas M, Regueira-Mendez C, and Takkouche B. Tobacco consumption and premenstrual syndrome: A case-control study. PLoS ONE, 2019; 14(6):e0218794. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31226148

7. Hyland A, Piazza K, Hovey KM, Tindle HA, Manson JE, et al. Associations between lifetime tobacco exposure with infertility and age at natural menopause: The women's health initiative observational study. Tobacco Control, 2016; 25(6):706-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26666428

8. Oboni JB, Marques-Vidal P, Bastardot F, Vollenweider P, and Waeber G. Impact of smoking on fertility and age of menopause: A population-based assessment. BMJ Open, 2016; 6(11):e012015. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27864244

9. Yang HJ, Suh PS, Kim SJ, and Lee SY. Effects of smoking on menopausal age: Results from the korea national health and nutrition examination survey, 2007 to 2012. J Prev Med Public Health, 2015; 48(4):216-24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26265667

10. Zhu D, Chung HF, Pandeya N, Dobson AJ, Cade JE, et al. Relationships between intensity, duration, cumulative dose, and timing of smoking with age at menopause: A pooled analysis of individual data from 17 observational studies. PLoS Medicine, 2018; 15(11):e1002704. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30481189

11. Whitcomb BW, Purdue-Smithe AC, Szegda KL, Boutot ME, Hankinson SE, et al. Cigarette smoking and risk of early natural menopause. American Journal of Epidemiology, 2018; 187(4):696-704. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29020262

12. Cochran CJ, Gallicchio L, Miller SR, Zacur H, and Flaws JA. Cigarette smoking, androgen levels, and hot flushes in midlife women. Obstetrics and Gynecology, 2008; 112(5):1037-44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18978103

13. Anderson DJ, Chung HF, Seib CA, Dobson AJ, Kuh D, et al. Obesity, smoking, and risk of vasomotor menopausal symptoms: A pooled analysis of eight cohort studies. American Journal of Obstetrics and Gynecology, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31705884

14. Jenabi E and Poorolajal J. The association between hot flushes and smoking in midlife women: A meta-analysis. Climacteric, 2015; 18(6):797-801. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26488934

15. Smith RL, Flaws JA, and Gallicchio L. Does quitting smoking decrease the risk of midlife hot flashes? A longitudinal analysis. Maturitas, 2015; 82(1):123-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26149340

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18. Wesselink AK, Hatch EE, Rothman KJ, Mikkelsen EM, Aschengrau A, et al. Prospective study of cigarette smoking and fecundability. Human Reproduction, 2019; 34(3):558-67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30576495

19. Marom-Haham L and Shulman A. Cigarette smoking and hormones. Current Opinion in Obstetrics and Gynecology, 2016; 28(4):230-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27285958

20. Howe G, Westhoff C, Vessey M, and Yeates D. Effects of age, cigarette smoking, and other factors on fertility: Findings in a large prospective study. British Medical Journal (Clinical Research Edition), 1985; 290(6483):1697-700. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3924219

21. US Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm.

22. Aboulmaouahib S, Madkour A, Kaarouch I, Sefrioui O, Saadani B, et al. Impact of alcohol and cigarette smoking consumption in male fertility potential: Looks at lipid peroxidation, enzymatic antioxidant activities and sperm DNA damage. Andrologia, 2018; 50(3). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29164649

23. Anifandis G, Bounartzi T, Messini CI, Dafopoulos K, Sotiriou S, et al. The impact of cigarette smoking and alcohol consumption on sperm parameters and sperm DNA fragmentation (sdf) measured by halosperm((r)). Archives of Gynecology and Obstetrics, 2014; 290(4):777-82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24840110

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26. Boeri L, Capogrosso P, Ventimiglia E, Pederzoli F, Cazzaniga W, et al. Heavy cigarette smoking and alcohol consumption are associated with impaired sperm parameters in primary infertile men. Asian Journal of Andrology, 2019; 21(5):478-85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30829290

27. Bundhun PK, Janoo G, Bhurtu A, Teeluck AR, Soogund MZS, et al. Tobacco smoking and semen quality in infertile males: A systematic review and meta-analysis. BMC Public Health, 2019; 19(1):36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30621647

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31. Hamad MF, Dayyih WAA, Laqqan M, AlKhaled Y, Montenarh M, et al. The status of global DNA methylation in the spermatozoa of smokers and non-smokers. Reproductive Biomedicine Online, 2018; 37(5):581-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30366840

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33. Kovac JR, Khanna A, and Lipshultz LI. The effects of cigarette smoking on male fertility. Postgraduate Medicine, 2015; 127(3):338-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25697426

34. Laqqan M, Tierling S, Alkhaled Y, Porto CL, Solomayer EF, et al. Aberrant DNA methylation patterns of human spermatozoa in current smoker males. Reproductive Toxicology, 2017; 71:126-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28576685

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38. Rehman R, Zahid N, Amjad S, Baig M, and Gazzaz ZJ. Relationship between smoking habit and sperm parameters among patients attending an infertility clinic. Front Physiol, 2019; 10:1356. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31736779

39. Sharma R, Harlev A, Agarwal A, and Esteves SC. Cigarette smoking and semen quality: A new meta-analysis examining the effect of the 2010 World Health Organization laboratory methods for the examination of human semen. European Urology, 2016; 70(4):635-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27113031

40. Silva JV, Cruz D, Gomes M, Correia BR, Freitas MJ, et al. Study on the short-term effects of increased alcohol and cigarette consumption in healthy young men's seminal quality. Sci Rep, 2017; 7:45457. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28367956

41. Tang Q, Pan F, Wu X, Nichols CE, Wang X, et al. Semen quality and cigarette smoking in a cohort of healthy fertile men. Environ Epidemiol, 2019; 3(4):e055. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31538136

42. Zhang M, Zhang QS, Zheng HS, Wang XY, Feng SQ, et al. Clinical, demographic and psychological characteristics of infertile male smokers in northeast china. Journal of International Medical Research, 2016; 44(1):75-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26647076

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48. Costa RM and Peres L. Smoking is unrelated to female sexual function. Substance Use and Misuse, 2015; 50(2):189-94. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25290661

49. Choi J, Shin DW, Lee S, Jeon MJ, Kim SM, et al. Dose-response relationship between cigarette smoking and female sexual dysfunction. Obstet Gynecol Sci, 2015; 58(4):302-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26217601

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