What you need to know about nicotine and hormonal birth control

Many of us may know that approximately two-thirds of US people with ovaries ages 15-49 years use some form of birth control as a safe, effective, and truly life-changing tool to help prevent pregnancy. What's less commonly known is that certain forms of contraception come with serious side effects when coupled with risk factors like smoking cigarettes.

If you’re a smoker, or maybe just curious about the adverse link between nicotine and birth control, continue reading to discover which forms of birth control are fine to use while smoking and which should be avoided.

Here's the TL;DR before diving in:

• Combined hormonal birth control methods like combination birth control pills, the patch, and the ring aren't recommended if you're over age 35 and smoke cigarettes.

• Most e-cigarettes contain nicotine, which is also known to increase your blood pressure and heart rate. To be safe, it’s best to avoid any products that contain nicotine while on hormonal birth control.

• Non-hormonal birth control options (the copper IUD, barrier methods) and progestin-only contraceptives (the minipill, the hormonal IUD, the shot) won't interact with smoking cigarettes. The same goes for emergency contraception (like Plan B).

• If contraceptive pills are your first choice and you smoke cigarettes, consider speaking with your doctor about the progestin-only minipill.

• Smoking cigarettes can also impact your fertility, so if you're thinking about having kids in the future, quitting is a good idea.

OB-GYN and Modern Fertility medical advisor Dr. Eva Luo, MD, MBA, FACOG adds that while the rates of cigarette smoking are trending downward on a national level, it continues to be an important consideration when prescribing birth control. "Given the concern with cigarette smoking and fertility, and cigarette smoking and combined hormonal birth control, it is routinely screened for," she explains.

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Smoking cigarettes is linked to heart disease (causing one out of four deaths from cardiovascular disease), can double a person’s risk for stroke, can cause a spike in blood pressure and heart rate, and can increase your risk of blood clots.

"Smoking cigarettes alone is dangerous — and adding combined hormonal birth control onto it is like adding fuel to the fire," says Dr. Luo. Here's how:

• According to this report from the ​​Centers for Disease Control (CDC), combined hormonal birth control methods like combination birth control pills, the patch, and the ring should not be used if you're over age 35 and smoke cigarettes. Why? Research suggests that smoking cigarettes while taking oral contraceptives can increase your risk of serious cardiovascular side effects, such as stroke, heart attack (myocardial infarction), and blood clots (venous thromboembolism).

• Findings from the World Health Organization offer similar sentiments: Birth control pill users who smoke are at increased risk of heart attack compared with non-smokers, with a positive correlation between risk and number of cigarettes smoked per day.

• The American College of Obstetrician and Gynecologists (ACOG) has also weighed in here, advising doctors to prescribe combination oral contraceptives with caution (if at all) for women who are older than 35 years and smoke.

What’s the science here?

Nicotine exacerbates the existing risks of hormonal birth control for smokers and other vulnerable populations. While it's possible for birth control containing estrogen (like the pill) to increase blood pressure, the benefit of a reliable form of pregnancy prevention outweighs that potential risk for most people. But for those who smoke cigarettes, nicotine's effects on blood pressure, heart rate, and other causes of heart attacks lead to a heightened risk of heart attack, stroke, or blood clots compared with people who don’t smoke while using hormonal contraceptives.

There's another factor here aside from cardiovascular risk that suggests hormonal birth control isn't right for smokers: Research from three large clinical trials found that smokers taking the pill were more likely to experience spotting or bleeding than non-smokers, suggesting that nicotine might influence the way the body breaks down estrogen. Another concern is that spotting might turn people off from the pill, causing them to stop taking it and potentially be at risk of pregnancy.

Just like regular cigarettes, most e-cigarettes contain nicotine, which is known to increase your blood pressure and heart rate. To be safe, it’s best to avoid any products that contain nicotine while on hormonal birth control.

Yes. If you plan to take birth control while continuing to smoke cigarettes, it’s really just combined hormonal birth control methods — so the pill, patch, and ring — that should be avoided.

ACOG suggests alternative non-hormonal contraceptives like intrauterine devices (IUDs), specifically the copper IUD since it uses copper instead of hormones to prevent pregnancy. If the pill is still your first choice, speak with your doctor about progestin-only options: the minipill, the hormonal IUD, and the shot.

You might also consider the barrier methods of birth control: spermicide, condom, sponge, diaphragm, and cervical cap. Although slightly less effective than some of the previously mentioned options, they don’t contain hormones so shouldn’t pose an increased cardiovascular health risk.

Birth control aside, however, it's important to understand the risks of smoking cigarettes in general. In addition to the well-documented health effects (e.g., cardiovascular disease, lung cancer, stroke), smoking also speeds up egg-loss rate and reduces the chances of conception each cycle. If you're thinking about having kids in the future, quitting before trying to get pregnant will be beneficial.

Below, we're exploring some of the other ways smoking could impact contraceptives and seeing where the research stands.

Cannabis and birth control

At this point, there’s insufficient data to suggest that cannabis influences the effectiveness of birth control. Although some sources say that marijuana can temporarily elevate your heart rate and blood pressure, there’s just not enough research to showcase a similar relationship like with cigarettes and nicotine.

If you’re currently using marijuana for medicinal or recreational purposes and want to take birth control, consider speaking with your doctor to review potential health risks and the right options for you.

Smoking and emergency contraception

There are three types of emergency contraception designed to stop a pregnancy before it starts — none of which should impact your cardiovascular risk on top of the increased risk already associated with smoking:

• Over-the-counter pills containing levonorgestrel (like Plan B)

• Ulipristal acetate (under the name ella)

• The copper IUD (which can also serve as emergency contraception for up to five days after unprotected sex)

• The hormonal IUD (recent research shows this is also effective emergency contraception if used within five days of unprotected sex)

If you're currently smoking but ready to quit, when can you start hormonal birth control?

As described by the CDC, your body begins a series of changes within 20 minutes of your last cigarette. First your heart rate drops, then 2-3 months later so does your risk of a heart attack. Within the next 5-15 years, your stroke risk is comparable to a non-smoker’s.

You won't need to wait a decade to start the pill, but your timeline will likely be specific to your situation. If you’re thinking of kicking your smoking habit, consider asking your healthcare provider the following questions:

• Have you ever tried quitting nicotine before?

• How do you plan to quell the cravings and withdrawal symptoms? (Therapies like the patch and gum still contain nicotine.)

• Are there other lifestyle factors placing you at risk for cardiovascular disease?

• What birth control will you use in the meantime?

Your provider can help you figure out your path to quitting, as well as the right birth control methods for you through and after quitting. "Quitting can be a journey," adds Dr. Luo. "If the quitting journey is more of a yo-yo trajectory rather than just quitting cold turkey successfully, that's okay. We are here for you and will meet you where you are."

Some hormonal birth control methods, specifically combination birth control pills, can increase your risk of heart attack, blood clots, and stroke if you're over age 35 and smoke (or vape).

If you currently smoke cigarettes and are using birth control (or considering it), please speak up at your next doctor's appointment. The pill — ubiquitous in contraceptive culture — isn’t a safe option, but there are plenty of other ways to help prevent pregnancy. Still, it's important to remember that smoking cigarettes carries health risks on its own.

This article was medically reviewed by Dr. Eva Marie Luo, MD, MBA, FACOG, an OB-GYN at Beth Israel Deaconess Medical Center and Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.

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How we reviewed this article

Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

Current version

November 29, 2021

Written by

Alexandria Bachert

Fact checked by

Eva Marie Luo, MD, MBA, FACOG

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About the medical reviewer

Eva Marie Luo, MD, MBA, FACOG