This article was updated by FOLX Copywriter Katie Taibl, RN, on 5/11/23.
In our Ask a Clinician series, Adryan (they/them) dives into commonly asked questions from our community and beyond related to virtual healthcare topics and much more especially as they relate to the queer and transgender communities. Disclaimer: any information in this column is purely educational and is not to be used as medical advice.
For our sixth installment, they interviewed FOLX clinician Julia, WHNP (she/her) drawing upon her five years’ experience providing sexual and reproductive health services, especially abortion and contraceptive care in states where legal access to abortion is restricted. We specifically discussed birth control options and tobacco use, particularly via vaping.
What do we need to know before we dive deeper into birth control and vaping?
Before we get into this topic, we should cover some basics. Birth control can be separated into three different categories:
- non-hormonal birth control: copper IUD, condoms, diaphragm/cap
- “combination” hormonal birth control containing synthetic estrogen and synthetic progesterone: combination birth control pill, birth control patch, birth control ring
- progesterone-only hormonal birth control (does not contain synthetic estrogen): injectable depo-provera, hormonal IUDs like Mirena/Liletta/Kyleena/Skyla, a hormonal implant under the skin of the arm called Nexplanon, or the progesterone-only pill/mini-pill
All hormonal birth control methods have synthetic versions of progesterone in them. When people talk about “the birth control pill,” they’re typically referring to the combination birth control pill, meaning a birth control pill that contains a combination of estrogen and progesterone. The combination birth control pill, the patch, and the ring all contain similar amounts of estrogen and progesterone, but they deliver the medications to your body in different ways through an oral tablet, a patch worn on the skin, or a ring inserted into the vagina or front hole.
There are also birth control pills that don’t contain estrogen, which are often called progesterone-only pills or mini-pills. Progesterone-only pills need to be taken on a very strict schedule in order to work, so for most people they are less effective than other birth control options. Combination birth control pills give a lot more wiggle room with dose timing so for most people they are more effective.
Which hormonal method, or non-hormonal method is best for you will depend on a lot of factors: your age, your medical history, your preferences about side effects or risks of different methods, cost, how convenient a method is, how easy it is to stop and start, how well it works, and your goals for your method. I encourage you to speak directly with your healthcare provider about the right hormonal contraception for you.
Can you vape on birth control?
If you vape or smoke tobacco, such as with electronic cigarettes/e-cigarettes or traditional cigarettes, there is certainly a prescription birth control method out there for you.
Birth control methods containing estrogen slightly increase your risk of developing blood clots in your blood vessels like those that cause DVT (deep vein thrombosis or blood clots in the arms/legs), pulmonary embolism (blood clots in the lungs), heart attack, or stroke. In pregnancy, the risk of blood clots in your blood vessels also increases. It’s important for us to compare the risk of a birth control method with the risk of pregnancy. For most young healthy people who are not on hormonal birth control, the risk of a blood clot in your blood vessels is about 1 in 1,000. On birth control methods containing estrogen that risk increases to about 7 in 10,000. In pregnancy this risk is about 25-30 in 10,000, according to the 21st edition of Contraceptive Technology.
Using tobacco products or vaping increases your cardiovascular risk. Your risk of developing blood clots in your blood vessels is higher.
When your clinician considers which birth control methods are safe for you to use, they make a mental list of things about your health or lifestyle that might make you more likely to get one of these blood clots called risk factors. Risk factors might include high blood pressure, certain types of migraine headaches, being 35 years of age or older, a strong family history of blood clots, and tobacco/vape use. If you have a lot of things on your individualized risk factor list, it may not be a good idea for you to use birth control methods containing estrogen.
As a general rule, people who are 35 years or older who smoke tobacco products or vape should not use birth control methods with estrogen. While age and tobacco use pose higher risks for health problems, this general recommendation may depend a bit on how much a person 35 years or older smokes or vapes tobacco each day. Just like everything else in healthcare, this is a very individualized conversation where your personal history and goals need to be considered. However, people 35 years or older who smoke or vape can typically still use hormonal birth control methods that don’t contain estrogen like depo-provera, IUDs, hormonal implant in the arm, and progesterone-only pills.
Is it recommended that I stop consuming nicotine before going on birth control? Can I still smoke tobacco on birth control?
It’s not news to anybody that healthcare providers recommend you reassess your smoking habits. Science has proven time and time again how harmful tobacco, nicotine, and other smoke/vape additives are. They increase the risk of almost every type of cancer as well as heart disease and heart attacks, strokes, lung or breathing disease, and much more. That being said, these substances are addictive, so they are very difficult to quit. It often takes multiple tries and sometimes prescription medication like nicotine patches to successfully quit.
If you are younger than 35, you can still be prescribed birth control containing estrogen even if you smoke or vape. While quitting can be beneficial for your health, it's not required. Some people under 35 have certain risk factors for blood clots, which mean they still can’t use birth control with estrogen. It’s important to talk to your clinician about your individual risk.
If you are 35 years or older, your clinician will probably not prescribe you birth control containing estrogen unless you stop smoking/vaping. They will talk with you about other methods that don’t contain estrogen and make a plan for preventing pregnancy that will work for you and meet your goals.
Can I still vape or smoke THC while on birth control?
We have limited scientific evidence about vaping, especially vaping THC. If the way you consume cannabis doesn’t include tobacco or nicotine, it probably doesn’t increase your risk of blood clots. Some people might be using a spliff containing tobacco and marijuana mixed together or a vape cartridge with both THC and nicotine. If you are vaping/smoking THC with tobacco or nicotine mixed in, it may increase your risk for blood clots. If you are using pre-rolled tobacco cigarettes and removing all the tobacco, and then using the paper to smoke marijuana, you aren’t smoking any tobacco and your risk of blood clots is probably not increased.
Our goal is for you to feel comfortable enough with your FOLX clinician to talk to them about any medications or drugs you are using, whether they have been prescribed to you or not. It’s important for your health for us to know what you’re taking, so we recommend you tell us the full story.
Can I smoke tobacco or vape nicotine if I am prescribed estrogen for hormone replacement therapy (HRT)/gender affirming hormone therapy (GAHT)?
Quitting isn’t required in order to be prescribed estrogen HRT/GAHT here at FOLX. We recommend those who are able and interested in quitting tobacco to do so. However, if you can’t or don’t want to quit, even cutting back on how much you smoke and/or vape will be better for your health, especially your cardiovascular health.
Recommendations for who can use estrogen as part of gender affirming care are less strict than they are for birth control. In gender affirming hormone therapy, the estrogen typically used is called 17β estradiol while the estrogen in birth control pills is called ethinyl estradiol. 17β estradiol is thought to be safer than ethinyl estradiol, so it can still be prescribed for people who wouldn’t be candidates for birth control pills. Another reason the recommendations are less strict in gender affirming hormone therapy is that people who need feminizing therapy don’t have alternative options other than 17β estradiol and feminizing therapy is absolutely essential for their health and well-being. Conversely, people who need birth control can use a range of methods that don’t contain ethinyl estradiol.
There may still be circumstances where your clinician considers it too dangerous for you to use estradiol for feminization while you are still smoking and/or vaping. Your clinician will ask you questions about your medical history and help you to understand your individual risk for blood clots if you were to take estradiol, and whether this changes if you use sublingual tablets, patches, or injections.
What factors are in my control to reduce my risk of blood clots?
Often, there are things in your medical history that you can’t control that increase your risk of blood clots, but there are also many things you can control. Improved nutrition, getting enough exercise and sleep, and decreasing stress can all help reduce your health risk of blood clots as well as keeping your blood pressure/cholesterol under control and addressing COPD or other lung conditions. If you have pre-diabetes or diabetes, getting good control of these conditions with lifestyle adjustments or medication can definitely reduce your risk of blood clots. And, of course, decreasing how much you smoke and/or vape tobacco or quitting altogether.
What do I do if I want to stop using tobacco or vaping?
The first thing to do if you want to quit tobacco/nicotine is to recognize that you are planning something that’s really tough, but that there’s support out there for you. There are many resources available online to help with smoking cessation (quitting) and your FOLX clinician can help too! There are prescription medications available to help reduce cravings or make using tobacco/nicotine less pleasurable, such as nicotine replacement patches/gum/sprays/inhalers/lozenges or medications that don’t contain nicotine like varenicline/Chantix or bupropion/Wellbutrin.
You can visit the The Centers for Disease Control and Prevention (CDC)’s resource page on smoking cessation to see a range of free resources and more information about medications. You can call 1-800-QUIT-NOW to get immediate evidence-based support making a plan to quit or suggestions for local resources. You can also check out SmokeFree.Gov for more information. Our FOLX clinicians can also meet with you in a virtual health care visit to help make a plan or prescribe medication for smoking cessation support.
Anything else you’d like to add?
Everybody’s medical history, risk factors, and birth control goals are different. The best way to learn the right form of birth control for you is to meet with a knowledgeable clinician and be honest with them about your medical history and preferences. There is a ton of information out there online about birth control that isn’t accurate. If you have concerns about certain birth control methods, let your clinician know! They can address these things head on and help you figure out if there’s any truth to them as well as what science can tell us about what you’ve heard or read.
Here at FOLX, we want to work together with you to figure out what’s going to help you be safe and successful in reaching your goals. You’re the expert on your life, we’re experts on birth control and gender affirming care—let’s team up!
- Reproductive Health Access Project: Get detailed information about birth control methods, how to use them, and what to do if you make a mistake using them.
- Bedsider: User-friendly, scientifically accurate info about birth control methods. It allows you to pick multiple methods and compare them all on one screen.
- CDC info on contraception
- Planned Parenthood
FOLX’s team of LGBTQ+ clinicians can talk with you about your individual risk factors, goals, and preferences for your birth control method. They can also talk with you about strategies for decreasing the amount you vape, smoke, or how to quit entirely. Existing FOLX members are encouraged to reach out to their care team via the Athena Patient Portal. If you’re a non-FOLX member, schedule a virtual healthcare visit to connect with one of our LGBTQ+-expert clinicians!