From the Guidelines
For smokers, the best contraceptive options are non-hormonal methods like copper IUDs (ParaGard), condoms, or progestin-only methods such as the hormonal IUD (Mirena, Kyleena, Liletta, Skyla), the implant (Nexplanon), or progestin-only pills (norethindrone 0.35mg daily). These are recommended because smoking combined with estrogen-containing contraceptives significantly increases the risk of blood clots, heart attacks, and strokes, especially in women over 35, as highlighted in the 2024 guideline for the primary prevention of stroke by the American Heart Association/American Stroke Association 1. The copper IUD is particularly effective, providing up to 10 years of protection with a 99% efficacy rate without any hormones.
Key Considerations
- Hormonal IUDs work locally in the uterus with minimal systemic absorption and last 3-7 years depending on the brand.
- The implant provides 3 years of protection with over 99% efficacy.
- Progestin-only pills must be taken at the same time each day to maintain effectiveness.
- Barrier methods like condoms offer the added benefit of STI protection but have lower typical-use effectiveness rates (82-85%).
- Ideally, smokers should also work toward smoking cessation, as this would eventually allow for more contraceptive options while improving overall health.
Evidence-Based Recommendation
The recommendation for non-hormonal or progestin-only contraception in smokers is based on the latest guidelines that emphasize the importance of minimizing the risk of stroke associated with estrogen-containing contraception in individuals with specific risk factors, such as tobacco use 1. While older guidelines and studies provide valuable insights into contraceptive management in various health conditions, the most recent and highest quality study guides the current recommendation for smokers to avoid estrogen-containing contraceptives due to the increased risk of cardiovascular events.
From the FDA Drug Label
WARNINGS Cigarette smoking greatly increases the possibility of suffering heart attacks and strokes. Women who use oral contraceptives are strongly advised not to smoke. The relationship between progestin-only oral contraceptives and these risks have not been established and there are no studies definitely linking progestin-only pill (POP) use to an increased risk of heart attack or stroke.
The best contraception for smokers is not explicitly stated in the label, but it can be inferred that progestin-only oral contraceptives like norethindrone may be a safer option compared to combined oral contraceptives, as the label states that the relationship between progestin-only oral contraceptives and the risks of heart attack or stroke has not been established. However, it is still advised that women who smoke should not use oral contraceptives due to the increased risk of heart attacks and strokes. 2
From the Research
Contraception Options for Smokers
- Smokers may face unique challenges when selecting a contraceptive method, as smoking can affect the efficacy and safety of certain options 3.
- Estrogen-containing methods, such as combined oral contraceptive pills, may increase the risk of venous thrombosis, which can be a concern for smokers 4.
- Progestin-only methods, such as progestin-only pills, injections, and implants, may be a suitable alternative for smokers, as they do not contain estrogen and are associated with lower risks 5, 6.
- Intrauterine devices (IUDs), such as the levonorgestrel-releasing intrauterine system (LNG-IUS), are highly effective and safe, and can be a good option for smokers who want a long-term contraceptive solution 7.
Considerations for Smokers
- Smokers may experience a higher frequency of spotting or bleeding when using oral contraceptives, which can lead to discontinuation of use and increased risk of unintended pregnancy 3.
- Clinicians should provide adequate counseling and information to smokers who are considering using progestin-only contraceptives, including potential side effects and benefits 6.
- Smokers should be informed about the potential risks and benefits of different contraceptive methods, and should be involved in the decision-making process to ensure that they choose a method that is suitable for their needs and preferences 4, 6.