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Smoking and the contraceptive pill

Here is what you need to know about the contraceptive pill and cigarette smoking: why it is dangerous to use both together, the risks for each type of contraceptive pill, the specific risks for women of different ages, how to avoid these risks, and what medical supervision is needed for women who both smoke and take the pill

The Contraceptive Pill and Smoking: A Dangerous Combination

If you smoke, combining the pill with cigarettes creates a significantly elevated risk to your health. This article explains why this combination is dangerous, the specific risks, and what you can do to protect yourself.

Understanding the Contraceptive Pill and Its Types

The contraceptive pill comes in two main forms:

  1. Combined Oral Contraceptives (COCs): These pills contain two hormones: estrogen and progestin. They work by preventing ovulation, thickening cervical mucus, and thinning the uterine lining. Most of the increased health risks when smoking are associated with COCs.
  2. Progestin-Only Pills (POPs) or “Mini-Pill”: These pills contain only progestin. They primarily work by thickening cervical mucus and thinning the uterine lining, sometimes suppressing ovulation. Generally, the risks associated with smoking are significantly lower with POPs compared to COCs, but discussing any concerns with your doctor is always important.

Why is Combining COCs and Smoking So Dangerous?

The estrogen component in Combined Oral Contraceptives is the key player in this risk equation. Estrogen can increase the risk of blood clot formation. Smoking, independently, also significantly damages blood vessels and promotes clot formation.

When you combine the two, you create a “perfect storm” that drastically multiplies your risk for serious cardiovascular events:

  • Blood Clots (Thrombosis): Smoking causes inflammation and damage to the lining of blood vessels, making them more prone to clotting. Estrogen in COCs also makes blood more likely to clot. Together, this dramatically increases the risk of a clot forming in a vein (deep vein thrombosis, DVT) or traveling to the lungs (pulmonary embolism, PE).
  • Heart Attack: Both smoking and COCs increase the workload on your heart and can contribute to the narrowing of arteries. When combined, this significantly raises the risk of a heart attack, especially as you get older.
  • Stroke: Smoking is a major risk factor for stroke due to its effects on blood vessels and blood pressure. COCs also independently increase stroke risk. The combination is particularly dangerous, as clots can travel to the brain, or blood vessels in the brain can rupture.

Specific Risks by Age Group

The dangers of smoking while on COCs are not uniform across all ages. The risk significantly increases with age, especially for women over 35.

  • Under 35: While the absolute risk is lower, it is still elevated compared to non-smoking pill users. Young women who smoke and take COCs face an increased risk of DVT, PE, heart attack, and stroke.
  • 35 and Older: For women aged 35 and above, particularly those who smoke 15 or more cigarettes per day, the risks of heart attack, stroke, and blood clots become critically high. Due to these severe risks, Combined Oral Contraceptives are generally contraindicated (not recommended and often medically prohibited) for smokers over the age of 35.

What to Do to Avoid These Risks

The message is clear: if you smoke, you should not be taking Combined Oral Contraceptives.

  1. Quit Smoking: This is the most effective action you can take. Quitting smoking will not only reduce the risks associated with contraception but will also dramatically improve your overall health and reduce your risk for numerous other diseases, including lung cancer, heart disease, and stroke.
  2. Discuss Alternatives with Your Doctor: If you cannot or choose not to quit smoking, you must explore other contraceptive methods.
    • Progestin-Only Pills (POPs): These are generally safer for smokers as they do not contain estrogen.
    • Intrauterine Devices (IUDs): Both hormonal and non-hormonal IUDs are highly effective and safe for smokers.
    • Contraceptive Implant (e.g., Nexplanon): A progestin-only implant that is very effective and safe for smokers.
    • Barrier Methods: Condoms, diaphragms, or cervical caps do not involve hormones and are safe for smokers, though less effective at preventing pregnancy compared to hormonal methods or IUDs.

Medical Advice for Women Who Smoke and Take the Pill

If you are a smoker and currently taking a Combined Oral Contraceptive, or considering starting one, urgent medical consultation is essential.

Your doctor will:

  • Thoroughly assess your individual risk factors: This includes your age, smoking history (how long and how much you smoke), family history of blood clots or heart disease, blood pressure, and any other existing medical conditions.
  • Strongly advise cessation of smoking: They will discuss the immediate and long-term benefits of quitting and may offer resources to help you.
  • Recommend alternative contraception: Given the elevated risks, your doctor will likely recommend switching to a progestin-only method (like the mini-pill, implant, or hormonal IUD) or a non-hormonal method (like a copper IUD or barrier methods).
  • Monitor your blood pressure: Regular blood pressure checks are crucial, as both smoking and COCs can affect blood pressure, further increasing cardiovascular risk.

Never start or continue Combined Oral Contraceptives without discussing your smoking habits truthfully with your healthcare provider. Hiding your smoking status can put your life at serious risk.

Please use the “Comments” field below to share your experience or to suggest improvements to this article.

References

Alicia M Allen, Andrea H Weinberger, Reagan R Wetherill, Carol L Howe, Sherry A McKee, Oral Contraceptives and Cigarette Smoking: A Review of the Literature and Future Directions, Nicotine & Tobacco Research, Volume 21, Issue 5, May 2019, Pages 592–601, https://doi.org/10.1093/ntr/ntx258

Vessey M, Painter R, Yeates D. Mortality in relation to oral contraceptive use and cigarette smoking. The Lancet, 362, 185-191.

Farley TM, Meirik O, Chang CL, et al Combined oral contraceptives, smoking, and cardiovascular risk. Journal of Epidemiology & Community Health 1998;52:775-785. https://doi.org/10.1136/jech.52.12.775

Nightingale, A. L., Lawrenson, R. A., Simpson, E. L., Williams, T. J., MacRae, K. D., & Farmer, R. D. T. (2000). The effects of age, body mass index, smoking and general health on the risk of venous thromboembolism in users of combined oral contraceptives. The European Journal of Contraception & Reproductive Health Care, 5(4), 265–274. https://doi.org/10.1080/13625180008500402

Pomp, E.R., Rosendaal, F.R. and Doggen, C.J.M. (2008), Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. Am. J. Hematol., 83: 97-102. https://doi.org/10.1002/ajh.21059

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