How nicotine attacks the blood vessels: Mapping the biological hierarchy of cardiovascular harm

A new review in Nature Reviews Cardiology offers the most comprehensive analysis yet of how nicotine harms the cardiovascular system. The study examines the biological pathways activated by nicotine exposure across various products, from cigarettes to e-cigarettes and oral tobacco products.

When nicotine binds to receptors in the blood vessel walls, it triggers a series of events that constrict blood vessels and promote inflammation and clot formation, increasing the risk of heart attacks and strokes. This pathway works regardless of the delivery method.

Nicotine suppresses a natural vasodilator called prostacyclin and increases a vessel-constricting hormone called endothelin-1. It also directly affects vascular smooth muscle cells, blocking potassium channels and disrupting calcium handling to favor constriction. These two mechanisms work together to create vessels that constrict more easily, relax less, and clot more readily.

The review establishes a hierarchy of vascular harm across different product categories, with combustible tobacco products causing the most damage, followed by heated products, aerosol devices, and finally oral nicotine products. Abstinence is the only risk-free option.

While e-cigarettes and heat-not-burn devices were marketed as less harmful, the data shows they still sit on a continuum of cardiovascular risk. Combustion reduction helps, but does not eliminate the risk entirely.

The review emphasizes that nicotine's cardiovascular toxicity is as strong as that of highly addictive drugs like cocaine and heroin. Given nicotine's dependence-forming potential and cardiovascular risks, the authors argue for a unified regulatory framework focused on nicotine rather than individual products. The European Society of Cardiology and the EU are calling for updated tobacco and nicotine regulations as part of a broader "Safe Hearts Plan."

To combat nicotine addiction, especially among young people, the review advocates for prevention efforts, taxation, flavor bans, and evidence-based cessation support. Nicotine's effects on the cardiovascular system make clear that it cannot be considered harmless, and regulatory measures must address this serious public health concern.