Nicotine in all forms is toxic to heart and blood vessels

Nicotine is toxic to the heart and blood vessels, regardless of whether it is consumed via a vape, a pouch, a shisha, or a cigarette, according to a new expert consensus report published in the European Heart Journal. The report brings together the results of the entire literature in the field and is the first to consider the harms of all nicotine products, rather than smoking only.

The report highlights a dramatic rise in the use of vapes, heated tobacco, and nicotine pouches, particularly among adolescents and young adults, with evidence that three-quarters of young adult vapers have never smoked before.

The authors of the report are calling for urgent action to curb the growing number of adolescents and young people becoming addicted to nicotine, particularly a ban on flavours and social media and influencer advertising, and effective taxation and regulation across all nicotine products.

The report was written by Prof Thomas Münzel, University Medical Centre, Mainz, Germany; Prof Filippo Crea, Catholic University of the Sacred Heart, Rome, Italy; Prof Sanjay Rajagopalan, Case Western Reserve School of Medicine, Cleveland, US; and Prof Thomas F Lüscher, Royal Brompton and Harefield Hospitals, London, UK, and President of the European Society of Cardiology.

The paper comes at a critical regulatory turning point, said the ESC, following the European Commission’s revised Tobacco Taxation Directive, which for the first time introduces a minimum tax on e-liquids, heated tobacco, and nicotine pouches.

Key findings of the expert consensus report include:

Nicotine is a potent cardiovascular toxin, causing damage to the heart and blood vessels, regardless of the delivery system.

No nicotine-containing product is safe for blood vessels or the heart. This includes e-cigarettes, heated tobacco, waterpipes, cigars, and oral nicotine pouches.

Youth addiction is rising rapidly, fuelled by flavours, social media marketing, and regulatory loopholes.

Passive exposure to smoke, vape, and heated tobacco emissions also causes vascular harm.

Vapes and pouches are not effective cessation tools, but rather are an entry point to smoking and often lead to dual use (alongside cigarettes).

Nicotine-related illnesses cost hundreds of billions of euros in healthcare and productivity losses every year.

Policy gaps persist across Europe, enabling new nicotine products to avoid taxation, packaging rules, and public-use restrictions.

However, the researchers caution that the longer-term effects of newer tobacco products are not yet known, so more research is needed to fully understand their impacts. They also acknowledge that many people use cigarettes alongside other nicotine products, making it harder to pinpoint the effects of the individual nicotine products.

The report’s authors call for:

Flavour bans for all nicotine products;

Taxation on all nicotine products that is proportional to nicotine content;

Plain packaging for all nicotine products;

Comprehensive indoor and outdoor smoke- and aerosol-free laws;

Strict online sales controls and social media advertising bans;

Integration of nicotine prevention into cardiovascular care;

National cardiovascular prevention plans that explicitly address nicotine.

Prof Münzel said: “Nicotine is not a harmless stimulant; it is a direct cardiovascular toxin.”

He maintained that the narrative of ‘safer nicotine’ must end. “Europe urgently needs unified regulation that covers all nicotine products, especially to protect adolescents, who are now the primary targets of aggressive marketing. Otherwise, we risk losing an entire generation to nicotine addiction.

Prof Crea added: “Our knowledge of cardiovascular risk keeps evolving. Obviously, we must abate the well-known traditional risk factors including hypertension, diabetes, obesity, and smoking. Traditional risk factors are only responsible for around half of cardiovascular disease. The remaining half is explained by emerging risk factors including pollution, depression, and infections. “Use of nicotine, in any form, also contributes to this cardiovascular risk. Cardiovascular disease remains the number one killer, so a strong, comprehensive call to action is needed.”

Prof Lüscher said this paper is a wake-up call for regulators. “The shift from cigarettes to e-cigarettes and flavoured pouches is no effective harm reduction; it is rather a transformation of addiction strategies.

“We need political action. Flavour bans, effective taxation, comprehensive advertising restrictions, and the inclusion of vaping and heated tobacco in all smoke-free laws are no longer optional – these are essential measures to prevent cardiovascular disease.”