If you’ve read more than a few articles on the Natural Womanhood website, you know we’re big fans of charting your menstrual cycle. The hormonal changes that naturally occur with the rise and fall of estrogen and progesterone at different parts of your cycle ensure healthy ovulation, and they are an important sign of health. When women use hormonal contraception, they miss out on the bone, brain, heart, immune, and breast benefits of ovulation. But that might not be all they miss out on. Could hormonal birth control also make it harder for women to quit smoking?
In the United States, about 13.5% of women smoke, just shy of 17.5% of the men who do. According to the CDC, women suffer more negative health effects from smoking, particularly related to their reproductive health, pregnancy complications, and disease risk. Additionally, smoking behaviors–including successful quitting–differ between men and women. Why might this be? A report from the NIH states that reproductive hormones, higher cortisol levels, and stronger cravings might make it harder for women to quit smoking.
More research in this area is important for understanding why and how these factors contribute to or hinder smoking cessation in women, but in this article, we’ll discuss what we know so far.
Investigators studied contraceptives and smoking
One of the most obvious differences between men and women is in their reproductive hormones, and women’s use of hormonal birth control. Even though OCs are contraindicated for smokers over age 35 due to risk of blood clots, it’s estimated that 1 out of 4 premenopausal women use oral contraceptives (OCs) [1]. Furthermore, nearly 1 in 2 premenopausal smokers are estimated to use some kind of hormonal contraception.
We know that all forms of hormonal contraception disrupt the menstrual cycle and the normal cyclical fluctuations of naturally occurring (i.e. “endogenous”) hormones. For this reason, women on OCs don’t have the typical levels of estrogen, progesterone, follicle stimulating hormone (FSH) or luteinizing hormone (LH) in their bodies that naturally cycling women do.
Recently, investigators from the University of Arizona and the University of Pennsylvania performed a literature review to highlight what’s currently known about whether OCs make women more or less likely to successfully quit smoking [1]. The review included 13 studies focused on nicotine metabolism and smoking cessation among oral contraceptive users.
The research on smoking in oral contraceptive users
Up to this point, little was known about how oral contraceptive use could be affecting women’s success in quitting smoking. The investigators looked at various studies on the effect OCs have on various smoking behaviors. They looked at four categories: nicotine metabolism, physiological stress response, smoking reward, and cravings [1].
Nicotine metabolism
Three studies identified faster metabolism of nicotine in OC users, particularly those OCs containing synthetic estrogen. These results weren’t seen in women using progestin-only OCs.
Stress response
Six studies looked at the stress levels of women smokers while using OCs. Interestingly, regardless of smoking status, women using OCs had higher blood pressure in response to stress-inducing activities compared to women not using OCs. Women using OCs also had higher cortisol levels compared to nonusers. Overall, the data indicate a higher stress response in smokers who use OCs compared to those who don’t.
Level of satisfaction, aka smoking reward
Only one study investigated the level of satisfaction (smoking reward) women felt after lighting up a cigarette. They compared women using combination estrogen/progestin OC (the women were taking Tri-Sprintec™ for this study) to non-users. Tri-Sprintec™ is a triphasic type of OC, where each pill has the same level of estrogen but three different levels of progesterone. Some of the more commonly used OCs contain the same amounts of hormones for every day (i.e., monophasic pills).
Researchers polled the women twice during the month. For non-OC users, this was during the follicular (high estrogen, low progesterone) phase and the luteal (high progesterone) phase. For OC users, they polled the women during the low progestin (0.018 mg dose) portion of their regimen and again during the high progestin (0.025 mg dose) portion. OC users reported greater smoking reward when their progesterone was low, while non-OC users reported greater smoking satisfaction while their progesterone was high. The researchers didn’t speculate on the reason for this disparity.
How oral contraceptive use affects smoking cessation attempts
Taken together, these studies show significant differences when women who use OCs have cravings, nicotine withdrawal, and stress response compared to non- OC users. The studies suggested faster nicotine metabolism in women who used combination estrogen/progestin OCs, specifically due to the estrogen. This is important, because women who metabolize nicotine faster tend to smoke more cigarettes, have higher withdrawal symptoms, and have lower rates of success in smoking cessation [2].
The studies suggested faster nicotine metabolism in women who used combination estrogen/progestin OCs, specifically due to the estrogen. This is important, because women who metabolize nicotine faster tend to smoke more cigarettes, have higher withdrawal symptoms, and have lower rates of success in smoking cessation [2].
Interestingly, the researchers conducting the literature review cited another study that found the same pattern in pregnant women trying to quit smoking, also due to their much higher estrogen levels compared to non-pregnant women [3]. Therefore, OC use could make it more difficult for women to quit smoking.
The authors also identified evidence for worse stress response among OC users, regardless of smoking status, compared to non-OC users. If a woman on OCs is trying to quit smoking, the higher stress combined with more intense withdrawal symptoms and nicotine cravings could contribute to lower rates of success.
The bottom line on birth control and quitting smoking
If you are currently using oral contraceptives, know that your birth control may be working against your efforts to quit smoking. If you’ve tried to quit smoking many times in the past but have been unsuccessful so far, consider switching to a fertility awareness method for family planning, instead. And if you take OCs for reproductive issues, consult a healthcare professional trained in restorative reproductive medicine for alternative treatment options that don’t counteract your goal to quit smoking.
