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Cigarette Smoking Women of Reproductive Age Who Use Oral Contraceptives: Results from the 2002 and 2004 Behavioral Risk Factor Surveillance Systems
Women’s Health Issues 20-6 (2010) 380–385
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Original article
Cigarette Smoking Women of Reproductive Age Who Use Oral Contraceptives: Results from the 2002 and 2004 Behavioral Risk Factor Surveillance Systems Annette K. McClave, MPH a,*, Carol J. Hogue, PhD, MPH b, Larissa R. Brunner Huber, PhD, MPH c, Alexandra C. Ehrlich, MPH d a
Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia Rollins School of Public Health, Emory University, Atlanta, Georgia Department of Public Health Sciences, The University of North Carolina at Charlotte, Charlotte, North Carolina d Northrop Grumman Information Technology, Research Triangle Park, North Carolina b c
Article history: Received 18 December 2009; Received in revised form 18 June 2010; Accepted 21 June 2010
a b s t r a c t Background: Despite health warnings about the increased risk of cerebrovascular disease among women who smoke while using oral contraceptives (OCs), prior research suggests that OC use is still prevalent among women who smoke cigarettes. Our objective was to investigate the prevalence of OC use among cigarette smoking women of reproductive age in the United States. Study Design: We extracted data from the 2002 and 2004 Behavioral Risk Factor Surveillance System surveys of 76,544 women between 18 and 44 years of age who reported using some form of contraception. OC use, or self-reported use of ‘‘the pill,’’ was examined among those who currently smoke, either everyday or some days. Multivariable logistic regression models were used to compare OC use between smoking and nonsmoking women. Results: One fourth (26.9%) of U.S. women who smoke compared with 34.6% of nonsmoking women reported currently using OCs. After adjusting for age, race/ethnicity, marital status, education level, binge drinking, and health care coverage, women who smoke were 0.6 (95% confidence interval [CI], 0.6–0.7) times as likely to use OCs as nonsmoking women. Among women aged 35 to 44 years, the odds of OC use among smokers was even further reduced (odds ratio [OR], 0.3; 95% CI, 0.3–0.4) compared with nonsmokers. Conclusion: Among U.S. women of reproductive age who use contraception, particularly among women aged 35 to 44 years, those who smoke cigarettes are significantly less likely to use OCs than those who do not. Published by Elsevier Inc.
Introduction Despite the deleterious impact smoking has on health, approximately 17.4% of women in the United States currently smoke cigarettes (Centers for Disease Control and Prevention [CDC], 2008a), and current cigarette smoking ranges from 5.8% to 34.7% among women of reproductive age across all 50 states, DC, and U.S. territories (CDC, 2008b). Numerous studies have demonstrated that cigarette smoking is associated with poor The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. * Correspondence to: Annette K. McClave, Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Highway Mailstop K-50, Atlanta, GA, 30341. Phone: (770) 488-5361. E-mail address: [email protected] (A.K. McClave). 1049-3867/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.whi.2010.06.006
health outcomes, including coronary heart disease, stroke, and premature death (U.S. Department of Health and Human Services, 2004). In fact, women who smoke and die of smoking-related diseases lose an average of 14 years of life (U.S. Department of Health and Human Services, 2001). Previous literature also indicates that cigarette smoking interacts with certain types of birth control, including oral contraceptives (OCs; World Health Organization [WHO], 1995a; Godsland, Winkler, Lidegaard, & Crook, 2000; Goldbaum, Kendrick, Hogelin, & Gentry, 1987; Hannaford, 2000; Herings, Urquhart, & Leufkens, 1999; Keeling, 2003) and this joint interaction between cigarette smoking and OC use can result in poor health outcomes (Goldbaum et al., 1987; Cress, Holly, Ahn, Kristiansen, & Aston, 1994; Zimlichman et al., 2004). Over the past 20 years, there has been increased inquiry into the use of OCs among smokers to investigate these poor health
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outcomes. Although OCs carry several great benefits including convenience, a low failure rate, reduced risks of ovarian and endometrial cancer, and treatment of dysmenorrhea (Sherif, 1999), researchers have identified an increased risk for thrombolytic and cardiovascular diseases and higher mortality among women who use OCs and smoke cigarettes compared with women who use OCs and do not smoke (Godsland et al., 2000; Keeling, 2003; WHO, 1995b; Lawson, Davidson, & Jick, 1977; Tanis et al., 2001; Vessey, Painter, & Yeates, 2003). For example, the odds of developing a venous thromboembolism for OC users is three to four times greater than nonusers, and the odds among OC users who smoke is 8.8 times higher than nonusers (WHO, 1995a, 1995b; Farley, Meirik, Change, Marmot, & Poulter, 1995; Sidney, Petitti, Soff, Cundiff, Tolan & Quesenberry, 2004; Pomp, Rosendaal, & Doggen, 2008). Women who smoke and use OCs have a higher mortality rate than non-OC users, and the mortality rate is even higher for women who smoke 15 or more cigarettes per day (Vessey et al., 2003). Because these health outcomes are so serious and evidence is quite limited for the definitive impact of smoking on OC use, the American College of Obstetricians and Gynecologists (ACOG) has recommended that physicians prescribe combination OCs with caution to smoking women, particularly among women older than 35 years who smoke (ACOG, 2006). Combination OCs, or OCs containing two hormones (e.g., estrogen and progestin), are the most widely used OCs and bear the highest risk, and OCs are the leading method of contraception used by 11.6 million women in the United States (Mosher, Martinez, Chandra, Abma, & Willson, 2004). Thus, it is important to understand how many women smoke and use OCs (Sherif, 1999). Previous surveillance research on OC use and smoking has produced conflicting evidence. To our knowledge, the last U.S. study involving an analysis of surveillance data on smoking and OC use was based on data collected in 1988; results of that study indicated that 24.0% of OC users and 28% of nonusers smoked cigarettes (Barrett, Anda, Escobedo, Croft, Williamson, & Marks, 1994). Limited present-day information is available comparing the use of OCs among women who smoke cigarettes and nonsmoking women. Furthermore, considering women older than 35 years of age who smoke and use OCs are at a considerably higher risk for negative health outcomes (ACOG, 2006), age is a particularly important factor to incorporate into an analysis of OC use and cigarette smoking with more recent data. Therefore, in our study, we used the most recent data from the Behavioral Risk Surveillance Systems (BRFSS) to produce updated estimates of the prevalence of OC use among smoking and nonsmoking women using contraception, with a particular emphasis on OC use among smokers older than 35 years of age. Methods Although other data sources, such as the National Survey of Family Growth were considered, the BRFSS is the only U.S. dataset which includes variables of current smoking status and OC use. As a result, we used the BRFSS from 2002 and 2004 to estimate smoking prevalence among women of reproductive age using OCs (CDC, 2006). The BRFSS is a telephone-based survey used for tracking health conditions and risk behaviors in the United States in all 50 states as well as the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands, which collects
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data on a variety of health factors, including family planning. Family planning questions were last included in the 2004 BRFSS; however, to maximize sample size, we combined 2002 and 2004 BRFSS datasets. Only women between the ages of 18 and 44 (reproductive age) who had not had a hysterectomy and were not pregnant are asked family planning questions in the BRFSS, and only women who report using birth control are asked what method they currently use. As a result, our analysis was limited to women of reproductive age (18–44 years) who reported currently using some form of birth control. The 2002 BRFSS was administered to 148,702 women, 64,181 of whom were of reproductive age, and 37,756 of whom reported using some form of birth control (62.3% of women of reproductive age). The 2004 BRFSS was administered to 186,256 women, 72,768 of whom were of reproductive age and 43,247 of whom reported using some form of birth control (68.1% of women of reproductive age). Analyses were limited to 76,544 (n ¼ 35,203 in 2002 and n ¼ 41,341 in 2004) women of reproductive age who had complete information on smoking status, birth control use, and demographic information. In 2002 and 2004, respondents were first given some examples of forms of contraception and were asked, ‘‘Are you or your husband/partner doing anything now to keep you from getting pregnant?’’ Women who responded ‘‘yes’’ were then asked, ‘‘What are you or your [partner] doing now to keep you from getting pregnant?’’ Response options were read only when necessary, and verbal prompts varied little from 2002 to 2004. In 2002, respondents were also asked the follow-up question, ‘‘What other method are you also using to prevent pregnancy?’’ However, because this follow-up question was not asked in 2004, we did not analyze responses to it. Smoking status was determined from two questions (identical on the 2002 and 2004 BRFSS): 1) ‘‘Have you ever smoked 100 cigarettes in your entire lifetime?’’ and 2) ‘‘Do you now smoke cigarettes every day, some days, or not at all?’’ Current smokers were defined as women who have smoked 100 cigarettes in their lifetime and currently smoke everyday or some days (n ¼ 18,542). Nonsmokers included women who have never smoked 100 cigarettes (never smokers; n ¼ 46,236) as well as women who have smoked 100 cigarettes in their lifetime but do not currently smoke at all (former smokers; n ¼ 11,530). Response rates ranged from 42.2% to 82.6% (median, 58.3%) in 2002 and from 32.2% to 66.6% (median, 52.7%) in 2004. Analysis Because of the complex survey design of the BRFSS, the statistical software SUDAAN version 9.0.1 (RTI, Research Triangle Park, NC) was used to incorporate the primary sampling units, stratification, and post-stratification weights. All results are weighted to adjust for probability of selection and demographic distribution of the state. OC use was calculated by smoking status and Cochran-Mantel-Haenszel chi-square tests of association were conducted to determine significant differences (a ¼ 0.05). Multivariable logistic regression analyses were used to compare adjusted odds ratios (OR) and 95% confidence intervals (95% CIs) for OC use between smoking and nonsmoking women. Because we were particularly interested in age as an effect modifier, we also stratified these multivariable logistic regression models by age group: 18 to 24, 25 to 29, 30 to 34, 35 to 39, and 40 to 44 years. All logistic regression analyses controlled for age, education level, marital status, health care coverage, and race/ethnicity. We
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additionally controlled for binge drinking (defined as the consumption of five or more alcoholic beverages on any one occasion), because heavy alcohol use is associated with both smoking (Strine et al., 2005) and use of contraception (Coleman & Cater, 2005).
23.6% of contraceptive-using women who smoke reported having no health care coverage, whereas 16.6% of contraceptiveusing women who do not smoke reported having no health care coverage. Method of Contraception
Results Demographic Characteristics Approximately 13.9% of the contraceptive-using women in our sample were binge drinkers; 60.9% were married and 22.5% were single, 7.0% were members of an unmarried couple, and 6.5% were divorced; 65.8% were non-Hispanic Whites, 17.6% were Hispanic, and 10.7% were non-Hispanic Blacks; 22.8% were between 18 and 24 years of age, 17.2% were between 25 and 29 years of age, and 60.0% were 30 years of age or older; 10.2% had some high school or less education, 26.7% were high school graduates, 30.5% had some college or technical school, and 32.6% were college graduates or higher education (Table 1). One sixth (18.2%) of the sample reported having no health care coverage. More than one quarter of contraceptive-using women who smoke were between 18 and 24 (27.6%) and were more frequently single (27.7%) or separated (4.6%), binge drinkers (26.3%) than women who do not smoke (Table 1). More than one half of contraceptive-using women who smoke (51.8%) graduated from high school or had less education. Approximately
One third (32.8%) of contraceptive-using women of reproductive age reported using OCs for contraception (smokers, 39.4%; nonsmokers, 30.8%; Table 2). Another one third (32.8%) of these women reported either female or male sterilization (e.g., vasectomy or tubal ligation) as the form of contraception they used with their partner (smokers, 26.9%; nonsmokers, 34.6%). Approximately 17.4% reported using condoms, 4.8% reported using Depo-Provera, 3.4% reported using the rhythm method, and 2.7% reported using an intrauterine device. Other forms of contraception, such as withdrawal and the diaphragm were less common (<1.0%). The remaining 4.7% of contraceptiveusing women of reproductive age reported using some other form of contraception, including products such as contraceptive foam jelly or cream, Norplant, emergency contraception, Lunelle, and other methods (Table 2). OC Use and Smoking More than one quarter of contraceptive-using women who reported currently smoking also reported using OCs for contraception (26.9%; 95% CI, 25.8%–28.1%), whereas 34.6% (95% CI,
Table 1 Demographic Characteristics of Contraceptive Using Women of Reproductive Age (18–44 years), Stratified by Smoking Status, BRFSS, United States, 2002 and 2004 Characteristic
Age (yrs) 18–24 25–29 30–34 35–39 40–44 Marital status Married Divorced Widowed Separated Single Member of an unmarried couple Binge drinkingz Yes No Education level Some high school or less High school graduate or GED equivalent Some college (1–3 yrs) College graduate (4 yrs) Race/ethnicity White, non-Hispanic Black, non-Hispanic Other Race/multiracialdnon-Hispanic Hispanic Health care coverage Yes No
Nonsmokersy
Smokers*
Overall n
Weighted % (95% CI)
11,593 13,618 16,514 17,305 17,513
22.8 17.2 20.3 19.6 20.1
(22.2–23.4) (17.0–17.7) (20.0–20.8) (19.0–20.1) (20.0–20.6)
46,328 7,370 424 2,411 15,870 4,140
60.9 6.5 0.3 2.8 22.5 7.0
n
Weighted % (95% CI)
n
Weighted % (95% CI)
3,401 3,450 3,726 3,890 4,154
27.6 17.0 17.7 18.2 19.6
(26.3–28.8) (16.1–17.9) (16.8–18.6) (17.2–19.1) (18.6–20.6)
8,192 10,168 12,788 13,415 13,359
21.3 17.3 21.1 20.1 20.3
(20.6–22.0) (16.7–17.8) (20.5–21.6) (19.5–20.6) (19.7–20.9)
(60.3–61.5) (6.2–6.8) (0.3–0.4) (2.6–3.0) (22.0–23.1) (6.6–7.4)
8,539 2,924 180 930 4,631 1,417
46.5 11.4 0.7 4.6 27.7 9.1
(45.3–47.8) (10.7–12.2) (0.5–0.9) (4.1–5.2) (26.5–28.9) (8.4–9.9)
37,789 4,446 244 1,481 11,239 2,723
65.2 5.0 0.3 2.2 21.0 6.3
(64.5–65.9) (4.7–5.3) (0.2–0.3) (2.0–2.5) (20.4–21.6) (5.9–6.8)
10,226 66,317
13.9 (13.4–14.3) 86.1 (85.7–86.6)
4,551 14,070
26.3 (25.2–27.5) 73.7 (72.5–74.8)
5,675 52,247
10.1 (9.7–10.5) 89.9 (89.5–90.3)
5,718 20,893 23,253 26,679
10.2 26.7 30.5 32.6
(9.7–10.6) (26.2–27.3) (29.9–31.1) (32.0–33.1)
2,398 7,103 5,926 3,194
14.3 37.5 31.8 16.5
(13.3–15.3) (36.3–38.7) (30.6–33.0) (15.6–17.4)
3,320 13,790 17,327 23,485
8.9 23.5 30.2 37.4
(8.4–9.4) (22.9–24.1) (29.5–30.9) (36.7–38.1)
56,848 7,655 4,349 7,691
65.8 10.7 6.0 17.6
(65.1–66.4) (10.3–11.0) (5.7–6.4) (17.0–18.2)
14,823 1,406 1,208 1,184
76.5 8.7 5.4 9.5
(75.2–77.7) (7.9–9.4) (4.8–6.0) (8.6–10.5)
42,025 6,249 3,141 6,507
62.5 11.3 6.2 20.0
(61.8–63.2) (10.9–11.7) (5.8–6.6) (19.3–20.7)
64,034 12,509
81.8 (81.3–82.3) 18.2 (17.7–18.7)
14,182 4,439
76.4 (75.3–77.5) 23.6 (22.5–24.7)
49,852 8,070
83.5 (82.8–84.1) 16.6 (16.0–17.2)
Abbreviation: CI, confidence interval. * Smokers are women between 18 and 44 years of age who self-reported smoking 100 cigarettes in their lifetime and now smoke everyday or some days. y Nonsmokers are women between 18 and 44 years of age who self-reported never smoking 100 cigarettes in their life or smoked 100 cigarettes in their life but do not currently smoke at all. z Binge drinking is defined as drinking 5 alcoholic beverages on any one occasion.
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Table 2 Estimated Prevalence of Primary Method of Contraception Among Contraceptive Using Women of Reproductive Age (18–44 years), Stratified by Smoking Status: Behavioral Risk Factor Surveillance System, United States, 2002 and 2004 Characteristic
Sterilization (female or male) Oral contraceptives Condoms Diaphragm Intrauterine device Depo Provera Withdrawal Rhythm Some other method
Nonsmokersy
Smokers*
Overall n
Weighted % (95% CI)
n
Weighted % (95% CI)
n
Weighted % (95% CI)
28,896 24,079 11,613 656 2,010 3,451 437 2,270 3,131
32.8 32.8 17.4 0.7 2.7 4.8 0.7 3.4 4.7
8,308 4,533 2,642 105 453 1,267 106 383 824
39.4 26.9 16.5 0.6 2.3 6.6 0.7 2.3 4.7
20,588 19,546 8,971 551 1,557 2,184 331 1,887 2,307
30.8 34.6 17.7 0.8 2.9 4.3 0.7 3.7 4.7
(32.3–33.4) (32.2–33.4) (16.9–17.9) (0.6–0.8) (2.5–3.0) (4.5–5.1) (0.6–0.8) (3.1–3.6) (4.4–5.0)
(38.2–40.6) (25.8–28.1) (15.5–17.5) (0.5–0.8) (1.9–2.7) (6.0–7.2) (0.5–0.9) (1.9–2.7) (4.1–5.5)
(30.2–31.5) (33.9–35.3) (17.1–18.3) (0.7–0.9) (2.6–3.2) (4.0–4.6) (0.6–0.9) (3.4–4.0) (4.3–5.0)
Abbreviation: CI, confidence interval. * Smokers are women who self-reported having smoked 100 cigarettes in their lifetime and currently smoke everyday or some days. y Nonsmokers are women who self-reported having never smoked 100 cigarettes in their life or have smoked 100 cigarettes in their life but do not currently smoke at all.
33.9%–35.3%) of nonsmoking women were OC users (Table 3). Among contraceptive-using women who smoke, OC use was highest among those between the ages of 18 and 24 (45.6%; 95% CI, 42.9%–48.4%), single women (42.4%; 95% CI, 39.9%–45.0%), binge drinkers (36.4%; 95% CI, 33.9%–38.8%), college graduates (38.7%; 95% CI, 35.9%–41.7%), non-Hispanic Whites (29.2%; 95%
CI, 28.0%–30.5%), and those with health care coverage (28.1%; 95% CI, 26.8%–29.4%; Table 3). When compared with nonsmokers, contraceptive-using women who smoke cigarettes were 0.7 times as likely to report using OCs (OR, 0.7; 95% CI, 0.6–0.7; data not shown). Chi-square tests indicated OC use was more common for
Table 3 Estimated Prevalence of Oral Contraceptive Use Among U.S. Women of Reproductive Age (18–44 years), by Smoking Status and Selected Characteristics: Behavioral Risk Factor Surveillance System, United States, 2002 and 2004 Characteristic
Sample Size
Oral Contraceptive Use
Overall Age (yrs) 18–24 25–29 30–34 35–39 40–44 Marital status Married Divorced Widowed Separated Single Member of an unmarried couple Binge drinkingz Yes No Education level Some high school or less High school graduate or GED equivalent Some college (1–3 yrs) College graduate (4 yrs) Race/ethnicity White, non-Hispanic Black, non-Hispanic Other race/multiracialdnon-Hispanic Hispanic Health care coverage Yes No
Prevalence Ratio Nonsmokersy
Smokers* n
Weighted % (95% CI)
n
Weighted % (95% CI)
76,543
4,533
26.9 (25.8–28.1)
19,546
34.6 (33.9–35.4)
0.78
11,593 13,618 16,514 17,305 17,513
1,604 1,245 914 489 281
45.6 (42.9–48.4) 39.0 (36.2–41.9) 24.5 (22.3–26.9) 11.3 (9.7–13.3) 6.8 (5.6–8.2)
4,450 4,713 4,496 3,366 2,521
51.7 44.9 34.1 24.7 18.1
(49.7–53.6) (43.2–46.7) (32.7–35.6) (23.5–26.0) (17.0–19.3)
0.88 0.87 0.72 0.46 0.38
46,328 7,370 424 2,411 15,870 4,140
1,506 537 27 129 1,837 497
18.4 18.0 23.0 19.0 42.4 38.8
(17.1–19.8) (15.8–20.4) (10.5–43.3) (14.3–24.9) (39.9–45.0) (34.4–43.3)
10,905 1,420 50 386 5,514 1,271
29.9 33.0 19.6 25.1 47.7 45.0
(29.1–30.7) (30.5–35.6) (13.1–28.3) (21.1–29.6) (46.1–49.5) (41.6–48.5)
0.62 0.55 1.17 0.76 0.89 0.86
10,226 66,317
1,506 3,027
36.4 (33.9–38.8) 23.5 (22.3–24.8)
2,565 16,981
47.0 (44.7–49.3) 33.2 (32.5–33.9)
0.77 0.71
5,718 20,893 23,253 26,697
323 1,502 1,546 1,162
15.3 23.5 30.1 38.7
(12.7–18.3) (21.8–25.2) (28.0–32.3) (35.9–41.7)
762 3,693 5,634 9,457
24.2 27.6 35.1 41.0
(21.6–26.9) (26.3–29.0) (33.8–36.5) (40.0–42.1)
0.63 0.85 0.86 0.94
56,848 7,655 4,349 7,691
3,844 179 268 242
29.2 (28.0–30.5) 12.4 (9.9–15.4) 26.4 (21.2–32.4) 22.0 (17.9–26.7)
15,140 1,643 938 1,825
38.2 26.7 30.8 29.0
(37.4–39.0) (25.0–28.5) (27.5–34.3) (27.1–31.0)
0.76 0.46 0.86 0.76
64,034 12,509
3609 924
28.1 (26.8–29.4) 23.3 (21.1–25.5)
17,290 2,256
35.9 (35.2–36.7) 27.9 (26.1–29.8)
0.78 0.84
Abbreviation: CI, confidence interval. * Smokers are women who self-reported having smoked 100 cigarettes in their lifetime and currently smoke everyday or some days. y Nonsmokers are women who self-reported having never smoked 100 cigarettes in their life or have smoked 100 cigarettes in their life but do not currently smoke at all. z Binge drinking is defined as drinking 5 alcoholic beverages on any one occasion during the past month.
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nonsmokers in almost all demographic groups, with the exception of women who were widowed, separated, a member of an unmarried couple, college graduates, and non-Hispanics of other races (p > .01). Similar to smoking women, OC use among nonsmoking women was most common among those aged 18 to 24 years old (51.7%; 95% CI, 49.7–53.6), those who were a member of an unmarried couple (47.7%; 95% CI, 46.1%–49.5%), binge drinkers (47.0%; 95% CI, 44.7%–49.3%), those who graduated college (41.0%; 95% CI, 40.0%–42.1%), non-Hispanic Whites (38.2%; 95% CI, 37.4%–39.0%), and those with health care coverage (35.9%; 95% CI, 35.2%–36.7%; Table 3). Regression analyses suggested a significant linear relationship between OC use and age among both smoking and nonsmoking women (p < .01 and p < .01, respectively). Among contraceptive-using women who smoke, OC use decreased 4.23% (95% CI, 3.87%–4.58%) for each increasing year of age. Among contraceptive-using women who do not smoke, OC use decreased 3.21% (95% CI, 3.01%–3.42%) for each increasing year of age (data not shown). Analyses stratified by age group indicated that, with the exception of contraceptive-using women between the ages of 25 and 29 years, the odds of using OCs for smokers compared with the odds of using OCs for nonsmokers decreased as age increased (p < .01). Among contraceptive-using women 18 to 24 years of age, smokers reported an odds of using OCs 0.7 (95% CI, 0.6–0.9) times that of nonsmokers; among women 30 to 34 years of age, smokers reported an odds of using OCs 0.7 (95% CI, 0.6–0.7) times that of nonsmokers. Similarly, among contraceptive-using women 35 to 39 years of age, the likelihood of using OCs was lower for smokers than for nonsmokers (OR, 0.4; 95% CI, 0.3–0.4); among contraceptive-using women 40 to 44 years of age, smokers reported a 70% reduction in odds of OC use (OR, 0.3; 95% CI, 0.3–0.4) compared with nonsmokers. Notably, among contraceptive-using women between the ages of 25 and 29 years, smokers reported an OR of using OC 0.8 (95% CI, 0.7–0.9) times that of nonsmokers, which was borderline significant at a ¼ 0.01. Discussion Using a large, U.S., state-aggregated sample, we observed that contraceptive-using women of reproductive age who smoke cigarettes reported significantly less use of OCs than women who do not smoke cigarettes. This association held true even more so for cigarette smoking women over the age of 35. These data indicate that many clinicians and women do follow the suggested ACOG guidelines. The estimates in this report are consistent with the findings from previous studies. Similar to previous studies, overall OCs and sterilization methods were the most frequently used form of contraception among women of reproductive age (Mosher et al., 2004). It is interesting to note, however, that among women who smoke, the most prevalent form of contraception was a sterilization method, whereas among nonsmoking women, OC use was the most prevalent form of contraceptive use. Because many of the women who smoked cigarettes and used OCs were of younger age, these results are consistent with previous reports indicating that women of older age groups choose sterilization methods of contraception over all other methods (Mosher et al., 2004). Among both smoking and nonsmoking women of reproductive age, women between 25 and 29 years of age, single women, binge drinkers, women who graduated college, non-Hispanics Whites, and women with health care coverage were the most likely to use OCs. These results are consistent with
previous studies, which show the demographic characteristics of female OC users (Mosher et al., 2004). Our results indicated that smokers were significantly less likely to use OCs than nonsmokers, and OC use further declines among smokers as age increases. Stratified analyses suggest this relationship is particularly true for women over the age of 35 years. Previous research also suggests that younger women may smoke and use OCs more often than older women (Goldbaum et al., 1987). These findings are promising, in that ACOG guidelines do not recommend prescription of OCs to women over the age of 35 who smoke cigarettes. Therefore, these results indicate that clinicians as well as their patients follow ACOG guidelines in cautioning women 35 and older in OC use (ACOG, 2006). This conclusion is particularly encouraging for a number of reasons. First, previous research has observed steep increases in the incidence of arterial diseases among women over 35 years, and the combination of smoking and OC use among these women is associated with this increased risk (Farley, Meirik, Chang, & Poulter, 1998). Second, previous research has suggested women between 35 and 44 years of age are heavier smokers than younger women (CDC, 1991). There is an age-related increase in the prevalence of heavy smoking and women between the ages of 35 and 44 smoke more heavily than all younger age groups (Barrett et al., 1994; CDC, 1995). Assuming heavy smokers are more likely to be older, OC use among women between 35 and 44 may be even more dangerous. However, because smoking women over the age of 40 should never use OCs, and even light smoking among women age 35 to 40 requires medical caution against OC use (Hatcher et al., 2004), the OC use we observed among smoking women between 35 and 39 years (11.3%) and 40 and 44 years (6.8%) may be too high. Regardless, it is apparent that women who smoke cigarettes choose contraceptive methods differently than women who do not smoke cigarettes. Several limitations must be considered in the present study. Because we analyzed self-reported responses to a landline telephone-administered survey and response to the survey was just over 50%, there are several biases that may have been introduced. First, because literature indicates a growing number of young adults do not have landline telephones, nearly one in seven between 2004 and 2005 (Blumberg, Luke, & Cynamon, 2006), it is possible this age group, as well as populations without telephones, is underrepresented in our sample. Also, because smoking prevalence is lower among persons with only a landline telephone and higher among cell phone only respondents, as a result, risk behaviors such as smoking may be underestimated in this sample (Link, Battaglia, Frankel, Osborn, & Mokdad, 2007). Second, because response rates averaged 55.5% between 2002 and 2004, it is possible that nonresponse bias may impact the results of this study. However, post-stratification and weighting techniques helped minimize bias produced by noncoverage, undercoverage, and nonresponse. Third, all information in the BRFSS is self-reported and may be subject to certain biases as a result. However, previous research shows that smoking estimates obtained from selfreported, population-based surveys and self-reported OC use are accurate (Caraballo, Giovino, Pechacek, & Mowery, 2001; Romieu et al., 1989). A number of concerns may arise from the use of two separate BRFSS surveys from multiple years. Although the survey questions were identical for the most part, there were some small discrepancies between the 2002 and 2004 BRFSSs. Because the 2002 BRFSS allowed for two responses of contraceptive method, there is the potential for the 2002 BRFSS to
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capture more OC users than the 2004 survey. However, because only 0.5% of the sample reported OCs as their second method of contraception, assuming similar results in 2004, our analyses excluded a small number of OC users. Despite these limitations, the use of a large, state-aggregated sample permits generalization of these results to contraceptiveusing women of reproductive age in the United States and provides for more precise estimates. Because prior research strongly indicates that negative health outcomes may result from OC use among smoking women, it is important to note that cigarette-smoking women in the United States overall are less likely to use OCs than women who do not smoke cigarettes, regardless of age, race/ethnicity, education, marital status, binge drinking, and health care coverage. Future studies should continue to monitor contraceptive behavior, particularly OC use among smoking women and assess the health consequences associated with this behavior. References American College of Obstetricians and Gynecologists (ACOG). (2006). ACOG practice bulletin. No. 73: use of hormonal contraception in women with coexisting medical conditions. Obstetrics & Gynecology, 107(6), 1453–1472. Barrett, D. H., Anda, R. F., Escobedo, L. G., Croft, J. B., Williamson, D. F., & Marks, J. S. (1994). Trends in oral contraceptive use and cigarette smoking. Behavioral Risk Factor Surveillance System, 1982 and 1988. Archives of Family Medicine, 3(5), 438–443. Blumberg, S. J., Luke, J. V., & Cynamon, M. L. (2006). Telephone coverage and health survey estimates: Evaluating the need for concern about wireless substitution. American Journal of Public Health, 96(5), 926–931. Caraballo, R. S., Giovino, G. A., Pechacek, T. F., & Mowery, P. D. (2001). Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988–1994. American Journal of Epidemiology, 153(8), 807–814. Centers for Disease Control and Prevention (CDC). (1991). Current trends in cigarette smoking among reproductive-aged WomendBehavioral Risk Factor Surveillance System, 1989. MMWR Morbidity & Mortality Weekly Report, 40(42), 719–723. Centers for Disease Control and Prevention (CDC). (1995). Cigarette smoking among reproductive-aged womendBehavioral Risk Factor Surveillance System, 1989. MMWR Morbidity & Mortality Weekly Report, 40(42), 719–723. Centers for Disease Control and Prevention (CDC). (2006). Behavioral Risk Factor Surveillance System: Operational User’s Guide. Available: ftp://ftp.cdc.gov/ pub/Data/Brfss/userguide.pdf. Accessed May 15, 2006. Centers for Disease Control and Prevention (CDC). (2008a). Cigarette smoking among adultsdUnited States, 2007. MMWR Morbidity & Mortality Weekly Report, 57(45), 1221–1226. Centers for Disease Control and Prevention (CDC). (2008b). Smoking prevalence among women of reproductive agedUnited States, 2006. MMWR Morbidity & Mortality Weekly Report, 57(31), 849–852. Coleman, L. M., & Cater, S. M. (2005). A qualitative study of the relationship between alcohol consumption and risky sex in adolescents. Archives of Sexual Behavior, 34(6), 649–661. Cress, R. D., Holly, E. A., Ahn, D. K., Kristiansen, J. J., & Aston, D. A. (1994). Contraceptive use among women smokers and nonsmokers in the San Francisco Bay area. Preventive Medicine, 23(2), 181–189. Farley, T. M. M., Meirik, O., Chang, C. L., Marmot, M. G., & Poulter, N. R. (1995). Effect of different progestagens in low estrogen oral-contraceptives on venous thromboembolic disease. Lancet, 346(8990), 1582–1588. Farley, T. M. M., Meirik, O., Chang, C. L., & Poulter, N. R. (1998). Combined oral contraceptives, smoking, and cardiovascular risk. Journal of Epidemiology & Community Health, 52(12), 775–785. Godsland, I. F., Winkler, U., Lidegaard, O., & Crook, D. (2000). Occlusive vascular disorders in oral contraceptive users: Epidemiology, pathology, & mechanisms. Drugs, 60(4), 722–869. Goldbaum, G. M., Kendrick, J. S., Hogelin, G. C., & Gentry, E. M. (1987). The relative impact of smoking and oral contraceptive use on women in the United States. Journal of the American Medical Association, 258(10), 1339–1342. Hannaford, P. (2000). Cardiovascular events associated with different combined oral contraceptives: A review of current data. Drug Safety, 22(5), 361–371. Hatcher, R., Trussell, J., Stewart, F., Nelson, A. L., Cates, W., Jr., Guest, F., et al. (2004). Contraceptive Technology (18th ed). New York: Contraceptive Technology Communications, Inc.
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Herings, R., Urquhart, J., & Leufkens, H. (1999). Venous thromboembolism among new users of different oral contraceptives. Lancet, 354, 127–128. Keeling, D. (2003). Combined oral contraceptives and the risk of myocardial infarction. Annals of Medicine, 35, 413–418. Lawson, D., Davidson, J., & Jick, H. (1977). Oral contraceptive use and venous thromboembolism: Absence of an effect of smoking. British Medical Journal, 2, 729–730. Link, M. W., Battaglia, M. P., Frankel, M. R., Osborn, L., & Mokdad, A. H. (2007). Reaching the US cell phone generation: Comparison of cell phone survey results with an ongoing landline telephone survey. Public Opinion Quarterly, 71(5), 814–839. Mosher, W. D., Martinez, G. M., Chandra, A., Abma, J. C., & Willson, S. J. (2004). Use of contraception and use of family planning services in the United States: 1982–2002. Advance Data, 350, 1–36. Pomp, E. R., Rosendaal, F. R., & Doggen, C. J. M. (2008). Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. American Journal of Hematology, 83(2), 97–102. Romieu, I., Willett, W. C., Colditz, G. A., Stampfer, M. J., Rosner, B., Hennekens, C. H., et al. (1989). Prospective study of oral contraceptive use and risk of breast cancer in women. Journal of the National Cancer Institute, 81(17), 1313–1321. Sherif, K. (1999). Benefits and risks of oral contraceptives. American Journal of Obstetrics & Gynecology, 180(6), S343–S348. Sidney, S., Petitti, D. B., Soff, G. A., Cundiff, D. L., Tolan, K. K., & Quesenberry, C. P. (2004). Venous thromboembolic disease in users of low-estrogen combined estrogen-progestin oral contraceptives. Contraception, 70(1), 3–10. Strine, T. W., Okoro, C. A., Chapman, D. P., Balluz, L. S., Ford, E. S., Ajani, U. A., et al. (2005). Health-related quality of life and health risk behaviors among smokers. American Journal of Preventive Medicine, 28(2), 182–187. Tanis, B. C., van den Bosch, M. A. A. J., Kemmeren, J. M., Cats, V. M., Helmerhorst, F. M., Algra, A., et al. (2001). Contraceptives and the risk of myocardial infarction. New England Journal of Medicine, 345(25), 1787–1793. U.S. Department of Health and Human Services (USDHHS). (2001). Women and smoking: a report of the surgeon general. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. U.S. Department of Health and Human Services (USDHHS). (2004). The health consequences of smoking: a report of the surgeon general. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Vessey, M., Painter, R., & Yeates, D. (2003). Mortality in relation to oral contraceptive use and cigarette smoking. Lancet, 362(9379), 185–191. World Health Organization (WHO). (1995a). Effect of different progestagens in low oestrogen oral contraceptives on venous thromboembolic disease. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet, 346(8990), 1582–1588. World Health Organization (WHO). (1995b). Venous thromboembolic disease and combined oral contraceptives: results of international multicentre case-control study. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet, 346(8990), 1575–1582. Zimlichman, E., Mandel, D., Mimouni, F. B., Wartenfeld, R., Huerta, M., Grotto, I., et al. (2004). Oral contraceptive use and smoking habits in young Israeli women: A cross-sectional study. Israel Medical Association Journal, 6(9), 546–549.
Author Descriptions Annette K. McClave is an Epidemiologist for the Office on Smoking and Health at CDC. She studies issues related to adult tobacco use in the U.S., including mental health, regional variation of tobacco use, women’s health, and use of other tobacco products.
Dr. Carol J. Hogue is the Jules & Uldeen Terry Professor of Maternal and Child Health and a Professor of Epidemiology, Rollins School of Public Health, Emory University. She researches racial disparities in women’s and perinatal health, and health consequences of birth control.
Dr. Larissa R. Brunner Huber is an Assistant Professor of Epidemiology at the University of North Carolina, Charlotte. She has published a number of studies on maternal and child health, including obesity and contraceptive failure as well as the contraceptive choices of women.
Alexandra C. Ehrlich is a Biostatistician for Northrop Grumman and serves as a contractor to the National Center for Health Statistics (NCHS). She is an expert in access to and management of U.S. national datasets, particularly NCHS datasets.
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Original article
Cigarette Smoking Women of Reproductive Age Who Use Oral Contraceptives: Results from the 2002 and 2004 Behavioral Risk Factor Surveillance Systems Annette K. McClave, MPH a,*, Carol J. Hogue, PhD, MPH b, Larissa R. Brunner Huber, PhD, MPH c, Alexandra C. Ehrlich, MPH d a
Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia Rollins School of Public Health, Emory University, Atlanta, Georgia Department of Public Health Sciences, The University of North Carolina at Charlotte, Charlotte, North Carolina d Northrop Grumman Information Technology, Research Triangle Park, North Carolina b c
Article history: Received 18 December 2009; Received in revised form 18 June 2010; Accepted 21 June 2010
a b s t r a c t Background: Despite health warnings about the increased risk of cerebrovascular disease among women who smoke while using oral contraceptives (OCs), prior research suggests that OC use is still prevalent among women who smoke cigarettes. Our objective was to investigate the prevalence of OC use among cigarette smoking women of reproductive age in the United States. Study Design: We extracted data from the 2002 and 2004 Behavioral Risk Factor Surveillance System surveys of 76,544 women between 18 and 44 years of age who reported using some form of contraception. OC use, or self-reported use of ‘‘the pill,’’ was examined among those who currently smoke, either everyday or some days. Multivariable logistic regression models were used to compare OC use between smoking and nonsmoking women. Results: One fourth (26.9%) of U.S. women who smoke compared with 34.6% of nonsmoking women reported currently using OCs. After adjusting for age, race/ethnicity, marital status, education level, binge drinking, and health care coverage, women who smoke were 0.6 (95% confidence interval [CI], 0.6–0.7) times as likely to use OCs as nonsmoking women. Among women aged 35 to 44 years, the odds of OC use among smokers was even further reduced (odds ratio [OR], 0.3; 95% CI, 0.3–0.4) compared with nonsmokers. Conclusion: Among U.S. women of reproductive age who use contraception, particularly among women aged 35 to 44 years, those who smoke cigarettes are significantly less likely to use OCs than those who do not. Published by Elsevier Inc.
Introduction Despite the deleterious impact smoking has on health, approximately 17.4% of women in the United States currently smoke cigarettes (Centers for Disease Control and Prevention [CDC], 2008a), and current cigarette smoking ranges from 5.8% to 34.7% among women of reproductive age across all 50 states, DC, and U.S. territories (CDC, 2008b). Numerous studies have demonstrated that cigarette smoking is associated with poor The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. * Correspondence to: Annette K. McClave, Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Highway Mailstop K-50, Atlanta, GA, 30341. Phone: (770) 488-5361. E-mail address: [email protected] (A.K. McClave). 1049-3867/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.whi.2010.06.006
health outcomes, including coronary heart disease, stroke, and premature death (U.S. Department of Health and Human Services, 2004). In fact, women who smoke and die of smoking-related diseases lose an average of 14 years of life (U.S. Department of Health and Human Services, 2001). Previous literature also indicates that cigarette smoking interacts with certain types of birth control, including oral contraceptives (OCs; World Health Organization [WHO], 1995a; Godsland, Winkler, Lidegaard, & Crook, 2000; Goldbaum, Kendrick, Hogelin, & Gentry, 1987; Hannaford, 2000; Herings, Urquhart, & Leufkens, 1999; Keeling, 2003) and this joint interaction between cigarette smoking and OC use can result in poor health outcomes (Goldbaum et al., 1987; Cress, Holly, Ahn, Kristiansen, & Aston, 1994; Zimlichman et al., 2004). Over the past 20 years, there has been increased inquiry into the use of OCs among smokers to investigate these poor health
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outcomes. Although OCs carry several great benefits including convenience, a low failure rate, reduced risks of ovarian and endometrial cancer, and treatment of dysmenorrhea (Sherif, 1999), researchers have identified an increased risk for thrombolytic and cardiovascular diseases and higher mortality among women who use OCs and smoke cigarettes compared with women who use OCs and do not smoke (Godsland et al., 2000; Keeling, 2003; WHO, 1995b; Lawson, Davidson, & Jick, 1977; Tanis et al., 2001; Vessey, Painter, & Yeates, 2003). For example, the odds of developing a venous thromboembolism for OC users is three to four times greater than nonusers, and the odds among OC users who smoke is 8.8 times higher than nonusers (WHO, 1995a, 1995b; Farley, Meirik, Change, Marmot, & Poulter, 1995; Sidney, Petitti, Soff, Cundiff, Tolan & Quesenberry, 2004; Pomp, Rosendaal, & Doggen, 2008). Women who smoke and use OCs have a higher mortality rate than non-OC users, and the mortality rate is even higher for women who smoke 15 or more cigarettes per day (Vessey et al., 2003). Because these health outcomes are so serious and evidence is quite limited for the definitive impact of smoking on OC use, the American College of Obstetricians and Gynecologists (ACOG) has recommended that physicians prescribe combination OCs with caution to smoking women, particularly among women older than 35 years who smoke (ACOG, 2006). Combination OCs, or OCs containing two hormones (e.g., estrogen and progestin), are the most widely used OCs and bear the highest risk, and OCs are the leading method of contraception used by 11.6 million women in the United States (Mosher, Martinez, Chandra, Abma, & Willson, 2004). Thus, it is important to understand how many women smoke and use OCs (Sherif, 1999). Previous surveillance research on OC use and smoking has produced conflicting evidence. To our knowledge, the last U.S. study involving an analysis of surveillance data on smoking and OC use was based on data collected in 1988; results of that study indicated that 24.0% of OC users and 28% of nonusers smoked cigarettes (Barrett, Anda, Escobedo, Croft, Williamson, & Marks, 1994). Limited present-day information is available comparing the use of OCs among women who smoke cigarettes and nonsmoking women. Furthermore, considering women older than 35 years of age who smoke and use OCs are at a considerably higher risk for negative health outcomes (ACOG, 2006), age is a particularly important factor to incorporate into an analysis of OC use and cigarette smoking with more recent data. Therefore, in our study, we used the most recent data from the Behavioral Risk Surveillance Systems (BRFSS) to produce updated estimates of the prevalence of OC use among smoking and nonsmoking women using contraception, with a particular emphasis on OC use among smokers older than 35 years of age. Methods Although other data sources, such as the National Survey of Family Growth were considered, the BRFSS is the only U.S. dataset which includes variables of current smoking status and OC use. As a result, we used the BRFSS from 2002 and 2004 to estimate smoking prevalence among women of reproductive age using OCs (CDC, 2006). The BRFSS is a telephone-based survey used for tracking health conditions and risk behaviors in the United States in all 50 states as well as the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands, which collects
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data on a variety of health factors, including family planning. Family planning questions were last included in the 2004 BRFSS; however, to maximize sample size, we combined 2002 and 2004 BRFSS datasets. Only women between the ages of 18 and 44 (reproductive age) who had not had a hysterectomy and were not pregnant are asked family planning questions in the BRFSS, and only women who report using birth control are asked what method they currently use. As a result, our analysis was limited to women of reproductive age (18–44 years) who reported currently using some form of birth control. The 2002 BRFSS was administered to 148,702 women, 64,181 of whom were of reproductive age, and 37,756 of whom reported using some form of birth control (62.3% of women of reproductive age). The 2004 BRFSS was administered to 186,256 women, 72,768 of whom were of reproductive age and 43,247 of whom reported using some form of birth control (68.1% of women of reproductive age). Analyses were limited to 76,544 (n ¼ 35,203 in 2002 and n ¼ 41,341 in 2004) women of reproductive age who had complete information on smoking status, birth control use, and demographic information. In 2002 and 2004, respondents were first given some examples of forms of contraception and were asked, ‘‘Are you or your husband/partner doing anything now to keep you from getting pregnant?’’ Women who responded ‘‘yes’’ were then asked, ‘‘What are you or your [partner] doing now to keep you from getting pregnant?’’ Response options were read only when necessary, and verbal prompts varied little from 2002 to 2004. In 2002, respondents were also asked the follow-up question, ‘‘What other method are you also using to prevent pregnancy?’’ However, because this follow-up question was not asked in 2004, we did not analyze responses to it. Smoking status was determined from two questions (identical on the 2002 and 2004 BRFSS): 1) ‘‘Have you ever smoked 100 cigarettes in your entire lifetime?’’ and 2) ‘‘Do you now smoke cigarettes every day, some days, or not at all?’’ Current smokers were defined as women who have smoked 100 cigarettes in their lifetime and currently smoke everyday or some days (n ¼ 18,542). Nonsmokers included women who have never smoked 100 cigarettes (never smokers; n ¼ 46,236) as well as women who have smoked 100 cigarettes in their lifetime but do not currently smoke at all (former smokers; n ¼ 11,530). Response rates ranged from 42.2% to 82.6% (median, 58.3%) in 2002 and from 32.2% to 66.6% (median, 52.7%) in 2004. Analysis Because of the complex survey design of the BRFSS, the statistical software SUDAAN version 9.0.1 (RTI, Research Triangle Park, NC) was used to incorporate the primary sampling units, stratification, and post-stratification weights. All results are weighted to adjust for probability of selection and demographic distribution of the state. OC use was calculated by smoking status and Cochran-Mantel-Haenszel chi-square tests of association were conducted to determine significant differences (a ¼ 0.05). Multivariable logistic regression analyses were used to compare adjusted odds ratios (OR) and 95% confidence intervals (95% CIs) for OC use between smoking and nonsmoking women. Because we were particularly interested in age as an effect modifier, we also stratified these multivariable logistic regression models by age group: 18 to 24, 25 to 29, 30 to 34, 35 to 39, and 40 to 44 years. All logistic regression analyses controlled for age, education level, marital status, health care coverage, and race/ethnicity. We
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additionally controlled for binge drinking (defined as the consumption of five or more alcoholic beverages on any one occasion), because heavy alcohol use is associated with both smoking (Strine et al., 2005) and use of contraception (Coleman & Cater, 2005).
23.6% of contraceptive-using women who smoke reported having no health care coverage, whereas 16.6% of contraceptiveusing women who do not smoke reported having no health care coverage. Method of Contraception
Results Demographic Characteristics Approximately 13.9% of the contraceptive-using women in our sample were binge drinkers; 60.9% were married and 22.5% were single, 7.0% were members of an unmarried couple, and 6.5% were divorced; 65.8% were non-Hispanic Whites, 17.6% were Hispanic, and 10.7% were non-Hispanic Blacks; 22.8% were between 18 and 24 years of age, 17.2% were between 25 and 29 years of age, and 60.0% were 30 years of age or older; 10.2% had some high school or less education, 26.7% were high school graduates, 30.5% had some college or technical school, and 32.6% were college graduates or higher education (Table 1). One sixth (18.2%) of the sample reported having no health care coverage. More than one quarter of contraceptive-using women who smoke were between 18 and 24 (27.6%) and were more frequently single (27.7%) or separated (4.6%), binge drinkers (26.3%) than women who do not smoke (Table 1). More than one half of contraceptive-using women who smoke (51.8%) graduated from high school or had less education. Approximately
One third (32.8%) of contraceptive-using women of reproductive age reported using OCs for contraception (smokers, 39.4%; nonsmokers, 30.8%; Table 2). Another one third (32.8%) of these women reported either female or male sterilization (e.g., vasectomy or tubal ligation) as the form of contraception they used with their partner (smokers, 26.9%; nonsmokers, 34.6%). Approximately 17.4% reported using condoms, 4.8% reported using Depo-Provera, 3.4% reported using the rhythm method, and 2.7% reported using an intrauterine device. Other forms of contraception, such as withdrawal and the diaphragm were less common (<1.0%). The remaining 4.7% of contraceptiveusing women of reproductive age reported using some other form of contraception, including products such as contraceptive foam jelly or cream, Norplant, emergency contraception, Lunelle, and other methods (Table 2). OC Use and Smoking More than one quarter of contraceptive-using women who reported currently smoking also reported using OCs for contraception (26.9%; 95% CI, 25.8%–28.1%), whereas 34.6% (95% CI,
Table 1 Demographic Characteristics of Contraceptive Using Women of Reproductive Age (18–44 years), Stratified by Smoking Status, BRFSS, United States, 2002 and 2004 Characteristic
Age (yrs) 18–24 25–29 30–34 35–39 40–44 Marital status Married Divorced Widowed Separated Single Member of an unmarried couple Binge drinkingz Yes No Education level Some high school or less High school graduate or GED equivalent Some college (1–3 yrs) College graduate (4 yrs) Race/ethnicity White, non-Hispanic Black, non-Hispanic Other Race/multiracialdnon-Hispanic Hispanic Health care coverage Yes No
Nonsmokersy
Smokers*
Overall n
Weighted % (95% CI)
11,593 13,618 16,514 17,305 17,513
22.8 17.2 20.3 19.6 20.1
(22.2–23.4) (17.0–17.7) (20.0–20.8) (19.0–20.1) (20.0–20.6)
46,328 7,370 424 2,411 15,870 4,140
60.9 6.5 0.3 2.8 22.5 7.0
n
Weighted % (95% CI)
n
Weighted % (95% CI)
3,401 3,450 3,726 3,890 4,154
27.6 17.0 17.7 18.2 19.6
(26.3–28.8) (16.1–17.9) (16.8–18.6) (17.2–19.1) (18.6–20.6)
8,192 10,168 12,788 13,415 13,359
21.3 17.3 21.1 20.1 20.3
(20.6–22.0) (16.7–17.8) (20.5–21.6) (19.5–20.6) (19.7–20.9)
(60.3–61.5) (6.2–6.8) (0.3–0.4) (2.6–3.0) (22.0–23.1) (6.6–7.4)
8,539 2,924 180 930 4,631 1,417
46.5 11.4 0.7 4.6 27.7 9.1
(45.3–47.8) (10.7–12.2) (0.5–0.9) (4.1–5.2) (26.5–28.9) (8.4–9.9)
37,789 4,446 244 1,481 11,239 2,723
65.2 5.0 0.3 2.2 21.0 6.3
(64.5–65.9) (4.7–5.3) (0.2–0.3) (2.0–2.5) (20.4–21.6) (5.9–6.8)
10,226 66,317
13.9 (13.4–14.3) 86.1 (85.7–86.6)
4,551 14,070
26.3 (25.2–27.5) 73.7 (72.5–74.8)
5,675 52,247
10.1 (9.7–10.5) 89.9 (89.5–90.3)
5,718 20,893 23,253 26,679
10.2 26.7 30.5 32.6
(9.7–10.6) (26.2–27.3) (29.9–31.1) (32.0–33.1)
2,398 7,103 5,926 3,194
14.3 37.5 31.8 16.5
(13.3–15.3) (36.3–38.7) (30.6–33.0) (15.6–17.4)
3,320 13,790 17,327 23,485
8.9 23.5 30.2 37.4
(8.4–9.4) (22.9–24.1) (29.5–30.9) (36.7–38.1)
56,848 7,655 4,349 7,691
65.8 10.7 6.0 17.6
(65.1–66.4) (10.3–11.0) (5.7–6.4) (17.0–18.2)
14,823 1,406 1,208 1,184
76.5 8.7 5.4 9.5
(75.2–77.7) (7.9–9.4) (4.8–6.0) (8.6–10.5)
42,025 6,249 3,141 6,507
62.5 11.3 6.2 20.0
(61.8–63.2) (10.9–11.7) (5.8–6.6) (19.3–20.7)
64,034 12,509
81.8 (81.3–82.3) 18.2 (17.7–18.7)
14,182 4,439
76.4 (75.3–77.5) 23.6 (22.5–24.7)
49,852 8,070
83.5 (82.8–84.1) 16.6 (16.0–17.2)
Abbreviation: CI, confidence interval. * Smokers are women between 18 and 44 years of age who self-reported smoking 100 cigarettes in their lifetime and now smoke everyday or some days. y Nonsmokers are women between 18 and 44 years of age who self-reported never smoking 100 cigarettes in their life or smoked 100 cigarettes in their life but do not currently smoke at all. z Binge drinking is defined as drinking 5 alcoholic beverages on any one occasion.
A.K. McClave et al. / Women’s Health Issues 20-6 (2010) 380–385
383
Table 2 Estimated Prevalence of Primary Method of Contraception Among Contraceptive Using Women of Reproductive Age (18–44 years), Stratified by Smoking Status: Behavioral Risk Factor Surveillance System, United States, 2002 and 2004 Characteristic
Sterilization (female or male) Oral contraceptives Condoms Diaphragm Intrauterine device Depo Provera Withdrawal Rhythm Some other method
Nonsmokersy
Smokers*
Overall n
Weighted % (95% CI)
n
Weighted % (95% CI)
n
Weighted % (95% CI)
28,896 24,079 11,613 656 2,010 3,451 437 2,270 3,131
32.8 32.8 17.4 0.7 2.7 4.8 0.7 3.4 4.7
8,308 4,533 2,642 105 453 1,267 106 383 824
39.4 26.9 16.5 0.6 2.3 6.6 0.7 2.3 4.7
20,588 19,546 8,971 551 1,557 2,184 331 1,887 2,307
30.8 34.6 17.7 0.8 2.9 4.3 0.7 3.7 4.7
(32.3–33.4) (32.2–33.4) (16.9–17.9) (0.6–0.8) (2.5–3.0) (4.5–5.1) (0.6–0.8) (3.1–3.6) (4.4–5.0)
(38.2–40.6) (25.8–28.1) (15.5–17.5) (0.5–0.8) (1.9–2.7) (6.0–7.2) (0.5–0.9) (1.9–2.7) (4.1–5.5)
(30.2–31.5) (33.9–35.3) (17.1–18.3) (0.7–0.9) (2.6–3.2) (4.0–4.6) (0.6–0.9) (3.4–4.0) (4.3–5.0)
Abbreviation: CI, confidence interval. * Smokers are women who self-reported having smoked 100 cigarettes in their lifetime and currently smoke everyday or some days. y Nonsmokers are women who self-reported having never smoked 100 cigarettes in their life or have smoked 100 cigarettes in their life but do not currently smoke at all.
33.9%–35.3%) of nonsmoking women were OC users (Table 3). Among contraceptive-using women who smoke, OC use was highest among those between the ages of 18 and 24 (45.6%; 95% CI, 42.9%–48.4%), single women (42.4%; 95% CI, 39.9%–45.0%), binge drinkers (36.4%; 95% CI, 33.9%–38.8%), college graduates (38.7%; 95% CI, 35.9%–41.7%), non-Hispanic Whites (29.2%; 95%
CI, 28.0%–30.5%), and those with health care coverage (28.1%; 95% CI, 26.8%–29.4%; Table 3). When compared with nonsmokers, contraceptive-using women who smoke cigarettes were 0.7 times as likely to report using OCs (OR, 0.7; 95% CI, 0.6–0.7; data not shown). Chi-square tests indicated OC use was more common for
Table 3 Estimated Prevalence of Oral Contraceptive Use Among U.S. Women of Reproductive Age (18–44 years), by Smoking Status and Selected Characteristics: Behavioral Risk Factor Surveillance System, United States, 2002 and 2004 Characteristic
Sample Size
Oral Contraceptive Use
Overall Age (yrs) 18–24 25–29 30–34 35–39 40–44 Marital status Married Divorced Widowed Separated Single Member of an unmarried couple Binge drinkingz Yes No Education level Some high school or less High school graduate or GED equivalent Some college (1–3 yrs) College graduate (4 yrs) Race/ethnicity White, non-Hispanic Black, non-Hispanic Other race/multiracialdnon-Hispanic Hispanic Health care coverage Yes No
Prevalence Ratio Nonsmokersy
Smokers* n
Weighted % (95% CI)
n
Weighted % (95% CI)
76,543
4,533
26.9 (25.8–28.1)
19,546
34.6 (33.9–35.4)
0.78
11,593 13,618 16,514 17,305 17,513
1,604 1,245 914 489 281
45.6 (42.9–48.4) 39.0 (36.2–41.9) 24.5 (22.3–26.9) 11.3 (9.7–13.3) 6.8 (5.6–8.2)
4,450 4,713 4,496 3,366 2,521
51.7 44.9 34.1 24.7 18.1
(49.7–53.6) (43.2–46.7) (32.7–35.6) (23.5–26.0) (17.0–19.3)
0.88 0.87 0.72 0.46 0.38
46,328 7,370 424 2,411 15,870 4,140
1,506 537 27 129 1,837 497
18.4 18.0 23.0 19.0 42.4 38.8
(17.1–19.8) (15.8–20.4) (10.5–43.3) (14.3–24.9) (39.9–45.0) (34.4–43.3)
10,905 1,420 50 386 5,514 1,271
29.9 33.0 19.6 25.1 47.7 45.0
(29.1–30.7) (30.5–35.6) (13.1–28.3) (21.1–29.6) (46.1–49.5) (41.6–48.5)
0.62 0.55 1.17 0.76 0.89 0.86
10,226 66,317
1,506 3,027
36.4 (33.9–38.8) 23.5 (22.3–24.8)
2,565 16,981
47.0 (44.7–49.3) 33.2 (32.5–33.9)
0.77 0.71
5,718 20,893 23,253 26,697
323 1,502 1,546 1,162
15.3 23.5 30.1 38.7
(12.7–18.3) (21.8–25.2) (28.0–32.3) (35.9–41.7)
762 3,693 5,634 9,457
24.2 27.6 35.1 41.0
(21.6–26.9) (26.3–29.0) (33.8–36.5) (40.0–42.1)
0.63 0.85 0.86 0.94
56,848 7,655 4,349 7,691
3,844 179 268 242
29.2 (28.0–30.5) 12.4 (9.9–15.4) 26.4 (21.2–32.4) 22.0 (17.9–26.7)
15,140 1,643 938 1,825
38.2 26.7 30.8 29.0
(37.4–39.0) (25.0–28.5) (27.5–34.3) (27.1–31.0)
0.76 0.46 0.86 0.76
64,034 12,509
3609 924
28.1 (26.8–29.4) 23.3 (21.1–25.5)
17,290 2,256
35.9 (35.2–36.7) 27.9 (26.1–29.8)
0.78 0.84
Abbreviation: CI, confidence interval. * Smokers are women who self-reported having smoked 100 cigarettes in their lifetime and currently smoke everyday or some days. y Nonsmokers are women who self-reported having never smoked 100 cigarettes in their life or have smoked 100 cigarettes in their life but do not currently smoke at all. z Binge drinking is defined as drinking 5 alcoholic beverages on any one occasion during the past month.
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nonsmokers in almost all demographic groups, with the exception of women who were widowed, separated, a member of an unmarried couple, college graduates, and non-Hispanics of other races (p > .01). Similar to smoking women, OC use among nonsmoking women was most common among those aged 18 to 24 years old (51.7%; 95% CI, 49.7–53.6), those who were a member of an unmarried couple (47.7%; 95% CI, 46.1%–49.5%), binge drinkers (47.0%; 95% CI, 44.7%–49.3%), those who graduated college (41.0%; 95% CI, 40.0%–42.1%), non-Hispanic Whites (38.2%; 95% CI, 37.4%–39.0%), and those with health care coverage (35.9%; 95% CI, 35.2%–36.7%; Table 3). Regression analyses suggested a significant linear relationship between OC use and age among both smoking and nonsmoking women (p < .01 and p < .01, respectively). Among contraceptive-using women who smoke, OC use decreased 4.23% (95% CI, 3.87%–4.58%) for each increasing year of age. Among contraceptive-using women who do not smoke, OC use decreased 3.21% (95% CI, 3.01%–3.42%) for each increasing year of age (data not shown). Analyses stratified by age group indicated that, with the exception of contraceptive-using women between the ages of 25 and 29 years, the odds of using OCs for smokers compared with the odds of using OCs for nonsmokers decreased as age increased (p < .01). Among contraceptive-using women 18 to 24 years of age, smokers reported an odds of using OCs 0.7 (95% CI, 0.6–0.9) times that of nonsmokers; among women 30 to 34 years of age, smokers reported an odds of using OCs 0.7 (95% CI, 0.6–0.7) times that of nonsmokers. Similarly, among contraceptive-using women 35 to 39 years of age, the likelihood of using OCs was lower for smokers than for nonsmokers (OR, 0.4; 95% CI, 0.3–0.4); among contraceptive-using women 40 to 44 years of age, smokers reported a 70% reduction in odds of OC use (OR, 0.3; 95% CI, 0.3–0.4) compared with nonsmokers. Notably, among contraceptive-using women between the ages of 25 and 29 years, smokers reported an OR of using OC 0.8 (95% CI, 0.7–0.9) times that of nonsmokers, which was borderline significant at a ¼ 0.01. Discussion Using a large, U.S., state-aggregated sample, we observed that contraceptive-using women of reproductive age who smoke cigarettes reported significantly less use of OCs than women who do not smoke cigarettes. This association held true even more so for cigarette smoking women over the age of 35. These data indicate that many clinicians and women do follow the suggested ACOG guidelines. The estimates in this report are consistent with the findings from previous studies. Similar to previous studies, overall OCs and sterilization methods were the most frequently used form of contraception among women of reproductive age (Mosher et al., 2004). It is interesting to note, however, that among women who smoke, the most prevalent form of contraception was a sterilization method, whereas among nonsmoking women, OC use was the most prevalent form of contraceptive use. Because many of the women who smoked cigarettes and used OCs were of younger age, these results are consistent with previous reports indicating that women of older age groups choose sterilization methods of contraception over all other methods (Mosher et al., 2004). Among both smoking and nonsmoking women of reproductive age, women between 25 and 29 years of age, single women, binge drinkers, women who graduated college, non-Hispanics Whites, and women with health care coverage were the most likely to use OCs. These results are consistent with
previous studies, which show the demographic characteristics of female OC users (Mosher et al., 2004). Our results indicated that smokers were significantly less likely to use OCs than nonsmokers, and OC use further declines among smokers as age increases. Stratified analyses suggest this relationship is particularly true for women over the age of 35 years. Previous research also suggests that younger women may smoke and use OCs more often than older women (Goldbaum et al., 1987). These findings are promising, in that ACOG guidelines do not recommend prescription of OCs to women over the age of 35 who smoke cigarettes. Therefore, these results indicate that clinicians as well as their patients follow ACOG guidelines in cautioning women 35 and older in OC use (ACOG, 2006). This conclusion is particularly encouraging for a number of reasons. First, previous research has observed steep increases in the incidence of arterial diseases among women over 35 years, and the combination of smoking and OC use among these women is associated with this increased risk (Farley, Meirik, Chang, & Poulter, 1998). Second, previous research has suggested women between 35 and 44 years of age are heavier smokers than younger women (CDC, 1991). There is an age-related increase in the prevalence of heavy smoking and women between the ages of 35 and 44 smoke more heavily than all younger age groups (Barrett et al., 1994; CDC, 1995). Assuming heavy smokers are more likely to be older, OC use among women between 35 and 44 may be even more dangerous. However, because smoking women over the age of 40 should never use OCs, and even light smoking among women age 35 to 40 requires medical caution against OC use (Hatcher et al., 2004), the OC use we observed among smoking women between 35 and 39 years (11.3%) and 40 and 44 years (6.8%) may be too high. Regardless, it is apparent that women who smoke cigarettes choose contraceptive methods differently than women who do not smoke cigarettes. Several limitations must be considered in the present study. Because we analyzed self-reported responses to a landline telephone-administered survey and response to the survey was just over 50%, there are several biases that may have been introduced. First, because literature indicates a growing number of young adults do not have landline telephones, nearly one in seven between 2004 and 2005 (Blumberg, Luke, & Cynamon, 2006), it is possible this age group, as well as populations without telephones, is underrepresented in our sample. Also, because smoking prevalence is lower among persons with only a landline telephone and higher among cell phone only respondents, as a result, risk behaviors such as smoking may be underestimated in this sample (Link, Battaglia, Frankel, Osborn, & Mokdad, 2007). Second, because response rates averaged 55.5% between 2002 and 2004, it is possible that nonresponse bias may impact the results of this study. However, post-stratification and weighting techniques helped minimize bias produced by noncoverage, undercoverage, and nonresponse. Third, all information in the BRFSS is self-reported and may be subject to certain biases as a result. However, previous research shows that smoking estimates obtained from selfreported, population-based surveys and self-reported OC use are accurate (Caraballo, Giovino, Pechacek, & Mowery, 2001; Romieu et al., 1989). A number of concerns may arise from the use of two separate BRFSS surveys from multiple years. Although the survey questions were identical for the most part, there were some small discrepancies between the 2002 and 2004 BRFSSs. Because the 2002 BRFSS allowed for two responses of contraceptive method, there is the potential for the 2002 BRFSS to
A.K. McClave et al. / Women’s Health Issues 20-6 (2010) 380–385
capture more OC users than the 2004 survey. However, because only 0.5% of the sample reported OCs as their second method of contraception, assuming similar results in 2004, our analyses excluded a small number of OC users. Despite these limitations, the use of a large, state-aggregated sample permits generalization of these results to contraceptiveusing women of reproductive age in the United States and provides for more precise estimates. Because prior research strongly indicates that negative health outcomes may result from OC use among smoking women, it is important to note that cigarette-smoking women in the United States overall are less likely to use OCs than women who do not smoke cigarettes, regardless of age, race/ethnicity, education, marital status, binge drinking, and health care coverage. Future studies should continue to monitor contraceptive behavior, particularly OC use among smoking women and assess the health consequences associated with this behavior. References American College of Obstetricians and Gynecologists (ACOG). (2006). ACOG practice bulletin. No. 73: use of hormonal contraception in women with coexisting medical conditions. Obstetrics & Gynecology, 107(6), 1453–1472. Barrett, D. H., Anda, R. F., Escobedo, L. G., Croft, J. B., Williamson, D. F., & Marks, J. S. (1994). Trends in oral contraceptive use and cigarette smoking. Behavioral Risk Factor Surveillance System, 1982 and 1988. Archives of Family Medicine, 3(5), 438–443. Blumberg, S. J., Luke, J. V., & Cynamon, M. L. (2006). Telephone coverage and health survey estimates: Evaluating the need for concern about wireless substitution. American Journal of Public Health, 96(5), 926–931. Caraballo, R. S., Giovino, G. A., Pechacek, T. F., & Mowery, P. D. (2001). Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988–1994. American Journal of Epidemiology, 153(8), 807–814. Centers for Disease Control and Prevention (CDC). (1991). Current trends in cigarette smoking among reproductive-aged WomendBehavioral Risk Factor Surveillance System, 1989. MMWR Morbidity & Mortality Weekly Report, 40(42), 719–723. Centers for Disease Control and Prevention (CDC). (1995). Cigarette smoking among reproductive-aged womendBehavioral Risk Factor Surveillance System, 1989. MMWR Morbidity & Mortality Weekly Report, 40(42), 719–723. Centers for Disease Control and Prevention (CDC). (2006). Behavioral Risk Factor Surveillance System: Operational User’s Guide. Available: ftp://ftp.cdc.gov/ pub/Data/Brfss/userguide.pdf. Accessed May 15, 2006. Centers for Disease Control and Prevention (CDC). (2008a). Cigarette smoking among adultsdUnited States, 2007. MMWR Morbidity & Mortality Weekly Report, 57(45), 1221–1226. Centers for Disease Control and Prevention (CDC). (2008b). Smoking prevalence among women of reproductive agedUnited States, 2006. MMWR Morbidity & Mortality Weekly Report, 57(31), 849–852. Coleman, L. M., & Cater, S. M. (2005). A qualitative study of the relationship between alcohol consumption and risky sex in adolescents. Archives of Sexual Behavior, 34(6), 649–661. Cress, R. D., Holly, E. A., Ahn, D. K., Kristiansen, J. J., & Aston, D. A. (1994). Contraceptive use among women smokers and nonsmokers in the San Francisco Bay area. Preventive Medicine, 23(2), 181–189. Farley, T. M. M., Meirik, O., Chang, C. L., Marmot, M. G., & Poulter, N. R. (1995). Effect of different progestagens in low estrogen oral-contraceptives on venous thromboembolic disease. Lancet, 346(8990), 1582–1588. Farley, T. M. M., Meirik, O., Chang, C. L., & Poulter, N. R. (1998). Combined oral contraceptives, smoking, and cardiovascular risk. Journal of Epidemiology & Community Health, 52(12), 775–785. Godsland, I. F., Winkler, U., Lidegaard, O., & Crook, D. (2000). Occlusive vascular disorders in oral contraceptive users: Epidemiology, pathology, & mechanisms. Drugs, 60(4), 722–869. Goldbaum, G. M., Kendrick, J. S., Hogelin, G. C., & Gentry, E. M. (1987). The relative impact of smoking and oral contraceptive use on women in the United States. Journal of the American Medical Association, 258(10), 1339–1342. Hannaford, P. (2000). Cardiovascular events associated with different combined oral contraceptives: A review of current data. Drug Safety, 22(5), 361–371. Hatcher, R., Trussell, J., Stewart, F., Nelson, A. L., Cates, W., Jr., Guest, F., et al. (2004). Contraceptive Technology (18th ed). New York: Contraceptive Technology Communications, Inc.
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Author Descriptions Annette K. McClave is an Epidemiologist for the Office on Smoking and Health at CDC. She studies issues related to adult tobacco use in the U.S., including mental health, regional variation of tobacco use, women’s health, and use of other tobacco products.
Dr. Carol J. Hogue is the Jules & Uldeen Terry Professor of Maternal and Child Health and a Professor of Epidemiology, Rollins School of Public Health, Emory University. She researches racial disparities in women’s and perinatal health, and health consequences of birth control.
Dr. Larissa R. Brunner Huber is an Assistant Professor of Epidemiology at the University of North Carolina, Charlotte. She has published a number of studies on maternal and child health, including obesity and contraceptive failure as well as the contraceptive choices of women.
Alexandra C. Ehrlich is a Biostatistician for Northrop Grumman and serves as a contractor to the National Center for Health Statistics (NCHS). She is an expert in access to and management of U.S. national datasets, particularly NCHS datasets.