What birth control is recommended for a patient who uses electronic cigarettes (e-cigarettes)?

Birth Control Recommendations for E-Cigarette Users

E-cigarette use does not contraindicate any form of hormonal contraception, and patients who use e-cigarettes should be offered the full range of contraceptive options based on standard medical eligibility criteria, with combined hormonal contraceptives (CHCs) being safe and appropriate first-line options. 1

Key Distinction: E-Cigarettes vs. Conventional Cigarettes

The critical issue is that e-cigarette use is NOT equivalent to cigarette smoking when assessing contraceptive eligibility. The cardiovascular risks associated with combined hormonal contraceptives are specifically linked to conventional cigarette smoking, not e-cigarette use. 2

• FDA labeling for combined hormonal contraceptives explicitly warns that "cigarette smoking increases the risk of serious cardiovascular side effects" and states this risk "is quite marked in women over 35 years of age" who smoke 15 or more cigarettes per day. 2
• This warning applies specifically to combustible tobacco cigarettes, which contain harmful substances like hydrogen cyanide and carbon monoxide that are not present in e-cigarettes. 1
• E-cigarettes contain and emit potentially toxic substances, but evidence shows "significantly lower exposure to potentially toxic substances from e-cigarettes compared with combustible tobacco cigarettes." 1

Recommended Contraceptive Approach

First-Line Options

Combined hormonal contraceptives (CHCs) containing 30-35 μg ethinyl estradiol are appropriate first-line options for e-cigarette users without other cardiovascular risk factors. 1, 3

• CHCs can be initiated at any time if the provider is reasonably certain the patient is not pregnant. 1
• Blood pressure measurement is the only examination needed before CHC initiation. 1
• If started >5 days after menses began, backup contraception (condoms) should be used for 7 days. 1

Alternative Options

All contraceptive methods remain available to e-cigarette users, including:

• Progestin-only pills (POPs): Can be initiated anytime with no examination required; backup contraception needed for 2 days (norethindrone/norgestrel) or 7 days (drospirenone) if started >1-5 days after menses. 1
• Long-acting reversible contraceptives (LARCs):
  • LNG-IUD requires bimanual examination and cervical inspection; backup contraception for 7 days if >7 days after menses. 1
  • Etonogestrel implant requires no examination; backup contraception for 7 days if >5 days after menses. 1
  • Copper IUD requires bimanual examination; no backup contraception needed. 1
• DMPA injection: No examination required; backup contraception for 7 days if >7 days after menses. 1

Critical Caveats

When to Avoid CHCs in E-Cigarette Users

Avoid CHCs if the patient has additional cardiovascular risk factors, regardless of e-cigarette use:

• History of venous thromboembolism, stroke, cardiovascular disease, or peripheral vascular disease. 4
• Age >35 years AND concurrent conventional cigarette smoking (not e-cigarette use alone). 2
• Well-controlled hypertension, uncomplicated diabetes, depression, and uncomplicated valvular heart disease are NOT contraindications to CHCs. 4

Counseling Points

• Strongly advise against dual use of e-cigarettes and conventional cigarettes, as toxicant levels may be higher in dual users than cigarette-only users. 1
• If the patient is using e-cigarettes for smoking cessation, support this effort while providing contraception, as evidence shows e-cigarettes have "significantly lower exposure to potentially toxic substances" than cigarettes. 1
• Current evidence on long-term harms of e-cigarette use is insufficient, but short-term serious adverse events are rare. 1

Pregnancy Considerations

• If the patient becomes pregnant, discontinue all hormonal contraceptives immediately. 2
• E-cigarette use during pregnancy has unknown effects on the fetus; counsel on smoking cessation resources. 1