3.6 Reproductive health

Last updated: Feb 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; 2021. 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 Treatment of infertility including assisted reproduction

As detailed in Section 3.6.2, women who smoke have reduced fertility, as smoking has been found to affect ovarian function and reserve,43 and there is emerging evidence that fertility may also be reduced in male smokers.2

Smoking also has a negative impact on the outcomes of infertility treatment.44 In women participating in assisted reproduction programmes, smoking is associated with lower pregnancy rates, higher chances of miscarriage, and a lower probability of a live birth.44, 45 A meta-analysis found that smokers had a lower number of oocytes retrieved compared to non-smokers, and a reduced rate of fertilisation.45

There is also evidence that smokers undergoing assisted reproduction also have an increased risk of ectopic pregnancy.46

One study found that for couples undergoing in vitro fertilization (IVF) who smoked (either female, male or both), the risk of not achieving a pregnancy was about twice as high as for non-smokers.47 Researchers have estimated that women who smoke need up to twice the number IVF cycles to conceive and suggest there is a correlation between the number of smoking years and the risk of not conceiving through IVF.48 Smoking cessation for both women and men is recommended for couples aiming to become pregnant49, 50 and it has been suggested that access to fertility treatment should be conditional on quitting smoking.48

Interestingly, there is some evidence that paternal smoking can increase the rate of pregnancy loss after IVF, likely as a result of damage to spermatozoa.51

Of note, smoking appears to affect infant outcomes in assisted reproduction pregnancies in the same way as unassisted pregnancies52 (see Section 3.8).

3.6.4 Contraception

As detailed in Section 3.2, smoking causes coronary heart disease, increasing the risk two- to four-fold.21 The ‘combined’ oral contraceptive pill (which contains the hormone oestrogen) also increases the risk of myocardial infarction two-fold.53 Women who take the oral contraceptive pill and smoke have a 20-fold increase in the risk of coronary heart disease, compared with non-smokers who are not taking the contraceptive pill.54 The impact of smoking and the contraceptive pill is therefore ‘synergistic’, meaning that the risk of disease is multiplicative rather than additive. Heavier smokers have an even higher risk of coronary heart disease.55

Although the newer ‘lower dose’ versions of the contraceptive pill may be associated with a lesser risk of developing coronary heart disease, risk is still elevated in smokers. There is insufficient evidence to evaluate the risk profile of the ‘third-generation’ pills (containing 30 μg or less of ethynyl estradiol and either gestodene or desogestrel) combined with smoking, but clinicians are advised to be wary when prescribing oral contraceptives to smokers aged in their mid-30s and to exercise extreme caution or avoid using them altogether in smokers aged over 40 years.55

In past decades the risk of stroke, particularly subarachnoid haemorrhage, has been significantly higher among smokers using the contraceptive pill. However research published since the 1990s following up women using lower dose pills is conflicting; some studies show increased risk, other studies have shown no significant effect.55

There is some evidence to suggest that the combined contraceptive pill has a higher failure rate in smokers than in non-smokers.54

3.6.5 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.56 The 2014 US Surgeon General’s report concluded that smoking causes ED,57 and several more recent reviews further support this conclusion.58, 59 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.57

A study of about 130 Italian women found that smokers have decreased blood flow to genital blood vessels, which may impair sexual function.60 While some studies have found no relationship between smoking and sexual function among women,61 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).62 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.63

3.6.6 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 August  2021 )



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: https://www.cdc.gov/tobacco/data_statistics/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

16. Radin RG, Hatch EE, Rothman KJ, Mikkelsen EM, Sorensen HT, et al. Active and passive smoking and fecundability in Danish pregnancy planners. Fertility and Sterility, 2014; 102(1):183-91 e2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24746741

17. Sapra KJ, Barr DB, Maisog JM, Sundaram R, and Buck Louis GM. Time-to-Pregnancy Associated With Couples' Use of Tobacco Products. Nicotine and Tobacco Research, 2016; 18(11):2154-61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27190399

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

24. Antoniassi MP, Intasqui P, Camargo M, Zylbersztejn DS, Carvalho VM, et al. Analysis of the functional aspects and seminal plasma proteomic profile of sperm from smokers. BJU International, 2016; 118(5):814-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27208688

25. Asare-Anane H, Bannison SB, Ofori EK, Ateko RO, Bawah AT, et al. Tobacco smoking is associated with decreased semen quality. Reprod Health, 2016; 13(1):90. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27496053

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

28. Cui X, Jing X, Wu X, Wang Z, and Li Q. Potential effect of smoking on semen quality through DNA damage and the downregulation of Chk1 in sperm. Mol Med Rep, 2016; 14(1):753-61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27221653

29. Dai JB, Wang ZX, and Qiao ZD. The hazardous effects of tobacco smoking on male fertility. Asian Journal of Andrology, 2015; 17(6):954-60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25851659

30. Hamad M, Shelko N, Montenarh M, and Hammadeh ME. The impact of cigarette smoking on protamines 1 and 2 transcripts in human spermatozoa. Hum Fertil (Camb), 2019; 22(2):104-10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28969455

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

32. Harlev A, Agarwal A, Gunes SO, Shetty A, and du Plessis SS. Smoking and Male Infertility: An Evidence-Based Review. World J Mens Health, 2015; 33(3):143-60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26770934

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

35. Lee HD, Lee HS, Lee JS, Park YS, and Seo JT. Do cigarette smoking and obesity affect semen abnormality in idiopathic infertile males? World J Mens Health, 2014; 32(2):105-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25237661

36. Lingappa HA, Govindashetty AM, Puttaveerachary AK, Manchaiah S, Krishnamurthy A, et al. Evaluation of Effect of Cigarette Smoking on Vital Seminal Parameters which Influence Fertility. J Clin Diagn Res, 2015; 9(7):EC13-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26393133

37. Mostafa RM, Nasrallah YS, Hassan MM, Farrag AF, Majzoub A, et al. The effect of cigarette smoking on human seminal parameters, sperm chromatin structure and condensation. Andrologia, 2018; 50(3). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29124782

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

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57. US Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. 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, 2014. Available from: https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf.

58. Biebel MG, Burnett AL, and Sadeghi-Nejad H. Male Sexual Function and Smoking. Sex Med Rev, 2016; 4(4):366-75. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27872030

59. Kovac JR, Labbate C, Ramasamy R, Tang D, and Lipshultz LI. Effects of cigarette smoking on erectile dysfunction. Andrologia, 2015; 47(10):1087-92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25557907

60. Battaglia C, Battaglia B, Mancini F, Persico N, Nappi RE, et al. Cigarette smoking decreases the genital vascularization in young healthy, eumenorrheic women. Journal of Sexual Medicine, 2011; 8(6):1717-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21477023

61. 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

62. 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

63. Wen LM, Rissel C, Cheng Y, Richters J, and de Visser RO. Tobacco smoking and sexual difficulties among Australian adults: a cross-sectional study. Sexual Health, 2017; 14(4):313-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28514995