Jan. 10, 2026

Nicotine and the Cardiovascular System: Key Insights for Primary Care

This summary is based on the "Special Article" published in the European Heart Journal (2025), which provides a comprehensive policy blueprint regarding nicotine's impact on cardiovascular health

Overview: Nicotine as a Direct Cardiovascular Toxin

The central theme of this paper is that nicotine itself is a direct cardiovascular (CV) toxin, independent of whether it is delivered through combustion (cigarettes) or non-combustible methods like e-cigarettes, heated tobacco, or oral pouches. While tobacco smoking remains a leading cause of global mortality (responsible for approximately 2.25 million CV deaths in 2021) the rapid rise of novel nicotine products, particularly among youth, represents a significant new public health threat.

Key Pathophysiological Effects

Nicotine acts through several well-defined molecular and hemodynamic pathways that contribute to all stages of cardiovascular disease (CVD):

• Sympathetic Activation: Nicotine is a powerful sympathomimetic that increases heart rate, myocardial contractility, and blood pressure, thereby elevating myocardial oxygen demand.
• Vascular Damage: It impairs endothelial function (a key early marker of vascular damage) by inducing oxidative stress and inflammation.
• Arterial Stiffness: Both acute and chronic exposure to nicotine products increase vascular rigidity, which amplifies the workload on the heart and promotes premature vascular aging.
• Prothrombotic Effects: Nicotine enhances platelet aggregation and reduces fibrinolysis, increasing the risk of acute coronary syndromes.

Key Take-Home Messages

• No "Safe" Nicotine Product: There is no safe form of nicotine for the heart or blood vessels. While e-cigarettes and heated tobacco may contain fewer carcinogens than traditional cigarettes, they still deliver toxic doses of nicotine that impair vascular health.
• The "Safer Alternative" Illusion: Switching from cigarettes to e-cigarettes may reduce short-term vascular damage, but chronic use sustains CV risk. "Dual use" (using both cigarettes and e-cigarettes) is common and provides no significant health benefits over smoking alone.
• Passive Exposure is Harmful: Second-hand exposure to smoke, aerosols, or vapors from e-cigarettes and waterpipes (shisha) can cause measurable endothelial dysfunction within minutes, particularly in children and vulnerable groups.
• The Youth Addiction Crisis: Modern delivery systems, such as pod-based e-cigarettes using nicotine salts, deliver high doses of nicotine rapidly. These are often aggressively marketed with flavors that appeal to adolescents, creating a high-speed "on-ramp" for lifelong addiction.
• Cessation Best Practices:

-Record and Advise:Use every clinical encounter to offer brief advice and record tobacco/nicotine use in medical records.

-Evidence-Based Tools: First-line cessation strategies include varenicline, Nicotine Replacement Therapy (NRT), bupropion, and cytisine, combined with intensive behavioral support.

-E-Cigarettes are Not Recommended: Current WHO guidelines and the European Society of Cardiology do not recommend e-cigarettes as a standard cessation tool due to lack of long-term safety data.

Conclusion: A Call to Action for Clinical Practice and Policy

The paper concludes with a definitive stance: nicotine is an unequivocal cardiovascular toxin. The evidence across clinical, mechanistic, and epidemiological studies proves that damage is not limited to traditional cigarettes but extends to all modern delivery systems.

For the Clinician (GP & Cardiologist)

• Elevate Nicotine Management: Nicotine prevention and cessation must be treated with the same clinical urgency as managing hypertension or dyslipidaemia.
• Systemic Integration: Every patient consultation should include screening for all forms of nicotine use.
• Standard of Care: Effective management requires incorporating nicotine cessation into professional training, clinical guidelines, and ensuring reimbursement for both counseling and pharmacotherapy.

For Policymakers

• Strict Regulation: Governments must act decisively to ban flavored and synthetic nicotine products, enforce plain packaging, and restrict all forms of advertising.
• Environmental Protection: Expanding smoke-free and vapor-free laws to both indoor and outdoor public spaces is essential.
• Economic Levers: Implementation of harm-proportional taxation and the funding of robust, accessible cessation services.

The Bottom Line

Nicotine addiction is a structural determinant of health, not merely a lifestyle choice. Whether the delivery method is a traditional cigarette, a sleek vape pod, or a flavored pouch, the cardiovascular consequences (infarction, stroke, and death) remain a critical public health threat. There is no room for compromise; delay in regulation and clinical intervention directly results in lost lives and increased health inequalities.