Nicotine does have measurable effects on the cardiovascular system. That point is not in dispute. However, treating all nicotine products as equally harmful, regardless of whether they are smoked or smoke-free, is not supported by the balance of current evidence and risks undermining smoking cessation and broader public-health objectives.
Recent commentary has renewed attention on nicotine’s cardiovascular effects, but the way this evidence is framed and translated into policy matters. When distinctions between combustible and non-combustible products are blurred, regulation may fail to reflect relative risk and inadvertently discourage transitions away from smoking.
What the European Heart Journal Article Argues
A recent overview article published in the European Heart Journal, and reported by Medical Xpress, asserts that nicotine damages the heart and blood vessels “regardless of how it is consumed.” The authors group cigarettes, e-cigarettes, heated tobacco products, shisha, and oral nicotine pouches together and call for cigarette-style controls across all nicotine products. These include flavour bans, higher taxation, comprehensive advertising restrictions, and expanded smoke- and aerosol-free laws.
The article is not a new experimental or epidemiological analysis. Rather, it synthesises existing literature and extrapolates from this body of evidence to propose broad policy responses. In doing so, it largely collapses the distinction between combustible tobacco products and non-combustible nicotine delivery systems, despite the central role of combustion in driving smoking-related disease.
Why Risk Differentiation Matters
Combustible cigarettes expose users to thousands of toxicants through smoke, including carbon monoxide, fine particulates, oxidants, and numerous carcinogens. These constituents are responsible for the vast majority of smoking-related cardiovascular disease, cancer, and premature mortality. Non-combustible nicotine products remove combustion and substantially reduce exposure to many of these harmful substances, even though they are not risk-free.
This distinction is fundamental to the concept of the continuum of risk. While nicotine itself can cause acute physiological effects, such as temporary increases in heart rate and blood pressure, these effects are not equivalent to the cumulative, long-term damage associated with inhaling tobacco smoke.
Expert Response: Risks Are Not the Same
In expert commentary published by the Science Media Centre, Professor Peter Hajek of Queen Mary University of London cautioned that the European Heart Journal article misrepresents the evidence by failing to differentiate adequately between smoking and smoke-free nicotine use. He emphasised that while nicotine has cardiovascular effects, smoking introduces a wide range of additional toxins that dramatically increase the risk of heart disease and other serious conditions.
Presenting all nicotine products as equally dangerous risks discouraging smokers from switching away from cigarettes, despite evidence that moving to non-combustible alternatives can significantly reduce toxicant exposure and improve vascular health. From a harm-reduction perspective, this type of messaging may have the unintended consequence of prolonging smoking rather than reducing it.
What the Evidence on Nicotine Actually Shows
Recent evidence summaries from Action on Smoking and Health (ASH) conclude that nicotine is addictive but carries relatively limited direct health risks when separated from smoke, especially when compared with the harms of smoking. Nicotine replacement therapies are recognised as effective cessation tools and are listed by the World Health Organization as essential medicines, reflecting their accepted role in public health.
ASH notes that nicotine can cause short-term cardiovascular responses, but long-term evidence linking nicotine alone to major cardiovascular events such as heart attack or stroke remains weak. Large observational studies of people using nicotine replacement therapy have not shown the elevated risks observed in smokers. Moreover, research indicates that smokers who switch completely to vaping show early and meaningful improvements in vascular function compared with those who continue smoking.
Context and Nuance in Cardiovascular Effects
Laboratory and clinical studies demonstrate that nicotine activates the sympathetic nervous system and can transiently affect cardiovascular function. These findings are relevant, particularly for individuals with existing heart disease, and they underscore that nicotine is not benign. However, these acute effects must be understood in context, alongside the much greater and more complex harms caused by chronic exposure to cigarette smoke.
Long-term population data consistently show that the cardiovascular burden of smoking is driven primarily by combustion and the broader toxicant mixture, rather than by nicotine in isolation. This does not eliminate the need for caution or regulation, but it does argue strongly against treating all nicotine delivery systems as interchangeable in terms of risk.
Why “All Products Are Equal” Is a Policy Problem
Calls to regulate all nicotine products as if they were cigarettes risk erasing meaningful differences in harm. If adopted, such approaches could make lower-risk alternatives less accessible or less appealing to adult smokers, while doing little to address the root cause of tobacco-related disease: continued smoking.
A proportionate, evidence-aligned framework would discourage nicotine use among non-smokers and young people, while preserving clear incentives for smokers to switch away from combustible tobacco. This includes maintaining differentiated regulation that reflects relative risk, supporting accurate public communication, and continuing to invest in high-quality research without delaying action on the well-established harms of smoking.
Conclusion
Nicotine is addictive and not harmless. That reality should not be minimised. However, equating smoke-free nicotine products with cigarettes misrepresents the evidence and risks slowing progress toward reduced smoking prevalence. Public-health policy is strongest when it reflects nuance, proportionality, and the full weight of scientific evidence.
For regulators committed to reducing cardiovascular disease and smoking-related harm, recognising the continuum of risk is not a concession, it is a necessity.
