This guide brings together what public health bodies and official drug labels say about smoking for people who take, or are thinking of taking, hormonal birth control pills, and how hookah (shisha) fits into that picture. It covers the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and the package insert of a low-dose pill sold in Japan.
This article is not medical advice. If you have any questions about taking the pill and smoking, including hookah, please talk to the doctor who prescribes your pill or to a pharmacist.
At a glance: what public sources say
- The CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC 2024) classifies combined hormonal contraceptives (CHCs), which contain both an estrogen and a progestin, as an “unacceptable health risk” (Category 4) for people aged 35 or over who smoke 15 or more cigarettes a day.
- Combination oral contraceptive (COC) labels approved by the FDA carry a boxed warning: cigarette smoking increases the risk of serious cardiovascular events from COC use.
- In Japan, the package insert of a low-dose pill (for example, Triquilar 28) lists “smokers aged 35 or over who smoke 15 or more cigarettes a day” as a contraindication, and says people taking the pill should be advised to stop smoking.
- Hookah is a tobacco product and, except for nicotine-free flavors, contains nicotine.
- However, all of these standards are written in terms of cigarettes per day. There is no separate standard for hookah.
Which pills this guide is about
“The pill” can mean several different medicines. This guide is mainly about pills that contain two hormones, an estrogen and a progestin.
- Combined oral contraceptives (COCs): low-dose pills taken for contraception. In Japan these are often called OC.
- LEP (low-dose estrogen-progestin): a Japanese term for pills containing the same two hormones, prescribed to treat conditions such as painful periods.
- Combined hormonal contraceptives (CHCs): the umbrella term used in the CDC’s criteria for methods that contain an estrogen and a progestin. According to the CDC, CHCs include COCs, combined skin patches and combined vaginal rings.
Pills that contain only a progestin, often called the mini-pill or progestin-only pill (POP), are treated differently when it comes to smoking, as explained below.
The pill, blood clots and cardiovascular risk
The package insert for Triquilar 28, a low-dose pill sold in Japan, says that blood clots (thrombosis) can occur with its use, and lists age and smoking among the risk factors for thrombosis. It also notes reports that the risk of serious cardiovascular side effects increases with age and with the amount smoked, and for that reason says people taking the pill should be advised to stop smoking.
The CDC’s criteria explain the evidence behind its smoking classifications: COC users who smoked were at increased risk for cardiovascular diseases, especially myocardial infarction (heart attack), compared with those who did not smoke, and studies also showed an increased risk for myocardial infarction with an increasing number of cigarettes smoked per day.
The standards, side by side
| Source | What it says about smoking |
|---|---|
| CDC U.S. MEC 2024 (CHCs) | Smoker under 35: Category 2 / 35 or over, fewer than 15 cigarettes a day: Category 3 / 35 or over, 15 or more a day: Category 4 |
| CDC U.S. MEC 2024 (progestin-only pills and other progestin-only methods) | Category 1 for smoking, whatever the age or number of cigarettes |
| An FDA-approved COC label (example) | Boxed warning: cigarette smoking increases the risk of serious cardiovascular events from COC use; this risk increases with age, particularly over 35, and with the number of cigarettes smoked. COCs are contraindicated in women over 35 who smoke |
| In Japan: package insert for Triquilar 28 | Contraindicated in smokers aged 35 or over who smoke 15 or more cigarettes a day (there are reports that cardiovascular disorders such as myocardial infarction occur more easily). People taking the pill should be advised to stop smoking |
The CDC defines its categories as follows:
- Category 1: a condition for which there is no restriction for the use of the contraceptive method.
- Category 2: a condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
- Category 3: a condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
- Category 4: a condition that represents an unacceptable health risk if the contraceptive method is used.
As the table shows, the wording differs from source to source and country to country. Which standard applies to a particular person, taking into account their age and medical history, is for the prescribing doctor to decide.
Where does hookah fit?
Hookah is a tobacco product
Hookah is a tobacco product. Hookah tobacco is tobacco leaf mixed with sweeteners and flavorings (FDA), and except for nicotine-free flavors, it contains nicotine. The CDC says hookah smoke contains nicotine, tar and heavy metals, and that the charcoal can produce carbon monoxide and other harmful substances.
You can’t simply convert it into cigarettes
Every standard above is written as a number of cigarettes per day. In the public sources reviewed for this guide, there was no separate standard describing hookah in relation to the pill.
Some figures do compare hookah with cigarettes:
- CDC: in a typical session of about an hour, a person inhales around 90,000 ml of smoke, 100 to 200 times the amount from one cigarette, and is exposed to about 9 times the carbon monoxide and about 1.7 times the nicotine of a single cigarette.
- WHO Regional Office for the Eastern Mediterranean: the nicotine in one bowl of unflavored tobacco is equivalent to 2 to 12 cigarettes.
However, the UK’s National Centre for Smoking Cessation and Training (NCSCT) explains that it is difficult to measure hookah smoke under consistent conditions, because the way people smoke, the size of the pipe and the materials used all vary. These figures therefore change a great deal depending on the conditions. That is why you cannot work out for yourself that “I smoke hookah this many times a month, so it counts as this many cigarettes a day.”
What about nicotine-free hookah?
Nicotine-free flavors contain no nicotine, but because they are heated with charcoal, they still produce smoke and carbon monoxide (CDC). The pill labels and the CDC’s criteria describe smoking; they say nothing specific about nicotine-free hookah. Don’t decide for yourself about nicotine-free hookah either: ask your prescriber. For more, see What Is Nicotine-Free (Herbal) Shisha?.
What to tell your doctor or pharmacist
The Japanese package insert asks that people taking the pill be advised to stop smoking. If you take the pill, or are about to be prescribed it, it helps to tell your doctor or pharmacist the following:
- Whether you ever smoke hookah (and cigarettes, heated tobacco or e-cigarettes)
- How often you smoke, and how long each session lasts
- Whether you use nicotine-free flavors
- Your age and any past illnesses
Because hookah is smoked so differently from cigarettes, answering “I don’t smoke” can mean your doctor doesn’t get the full picture. If you are in Japan, you can describe it as シーシャ (shisha) or 水たばこ (mizu-tabako). For how hookah differs from cigarettes and other products, see Hookah vs Cigarettes.
FAQ
Can I smoke hookah while on birth control?
There is no standard specific to hookah, but hookah is a tobacco product that contains nicotine. The Japanese package insert asks that people taking the pill be advised to stop smoking. Don’t decide for yourself; talk to your prescriber or pharmacist.
Is nicotine-free hookah OK on the pill?
Nicotine-free hookah still produces smoke and carbon monoxide from the charcoal (CDC). The standards for the pill say nothing specific about nicotine-free hookah, so ask your prescriber.
What if I only smoke hookah once a month?
The public standards are written in cigarettes per day, and there is no standard for how often you smoke hookah. Tell your prescriber how often you smoke.
What about the mini-pill (progestin-only pill)?
In the CDC’s U.S. MEC 2024, smoking is Category 1 (no restriction) for progestin-only pills, whatever your age or how much you smoke. Which medicine suits you is still for your prescriber to decide.
I’m under 35. Does that mean it’s fine?
Under the CDC’s criteria, CHC use by smokers under 35 is Category 2. That is not the same as “no restriction,” and the Japanese package insert asks that anyone taking the pill be advised to stop smoking, regardless of age.
Summary
- Combining pills that contain an estrogen (COCs, LEP and other CHCs) with smoking is described as raising the risk of serious cardiovascular side effects.
- The CDC classifies age 35 or over with 15 or more cigarettes a day as Category 4, and the Japanese package insert lists smokers aged 35 or over who smoke 15 or more a day as a contraindication.
- The public standards are written in cigarettes per day; there is no separate standard for hookah.
- Hookah is a tobacco product that contains nicotine, and even nicotine-free hookah produces carbon monoxide.
- If you take the pill or are thinking about it, tell your prescriber or pharmacist about your smoking habits, including hookah.
For hookah’s health risks in general, see Is Hookah Dangerous?, and for pregnancy and breastfeeding, see Hookah While Pregnant or Breastfeeding.
How it works at shisha bar IORI (Gakugei-daigaku, Tokyo)
- We offer 36 nicotine-free flavors
- We ventilate the room thoroughly and check indoor carbon monoxide levels regularly with a CO monitor
- If you have any concerns, please ask our staff. For anything about your medication, please ask your doctor or pharmacist
References
- Centers for Disease Control and Prevention, “U.S. MEC: Combined Hormonal Contraceptives”
- Centers for Disease Control and Prevention, “Appendix A: Summary of Classifications for U.S. Medical Eligibility Criteria for Contraceptive Use, 2024”
- Centers for Disease Control and Prevention, “U.S. MEC: How to Use This Document”
- Centers for Disease Control and Prevention, “U.S. Medical Eligibility Criteria for Contraceptive Use, 2024” (MMWR)
- DailyMed (U.S. National Library of Medicine), Levonorgestrel and Ethinyl Estradiol Tablets label
- KEGG MEDICUS (JAPIC package insert), Triquilar 28 (Japanese)
- U.S. Food and Drug Administration, “Hookah Tobacco (Shisha or Waterpipe Tobacco)”
- Centers for Disease Control and Prevention, “Hookahs”
- WHO EMRO, “Tobacco Free Initiative fact sheet: waterpipe tobacco smoking”
- NCSCT, “Waterpipe tobacco smoking: briefing”
