December 18, 2025

expert reaction to report on nicotine and heart / blood vessels

A report published in the European Heart Journal looks at nicotine and the cardiovascular system. 

Dr Jasmine Khouja, Lecturer in Psychology at the University of Bath, said:

“This article is not a scientific study; the four experts in cardiology who wrote it describe it as an expert review, but no experts in vaping or nicotine research were included. The review states that nicotine is a cardiovascular toxin and that no nicotine product is safe or can be deemed safer. This is a dangerous statement that could encourage people who are using less harmful products (like nicotine patches or e-cigarettes) to start smoking again because cardiovascular experts are suggesting they are equally harmful. Nicotine indeed has effects on the cardiovascular system, but smoking adds extra risk by exposing people to a whole range of other chemicals and toxicants that harm the heart. People who smoke are more at risk of heart problems, but they are also more at risk of having cancer and many other health issues that are not linked to nicotine use, due to the combustion process and other chemicals and toxicants in cigarette smoke that are usually not found (or found at much lower levels) in products like vapes.

“The review does not accurately reflect the science, and the authors have made strong claims that are backed by no/limited evidence or have contradictory evidence that is not discussed. The authors have made claims about the effects of using e-cigarettes and then cited studies that didn’t even look at e-cigarettes to support their claim: e.g. ‘Switching from cigarettes to e-cigarettes may reduce short-term vascular damage, but chronic use continues to sustain CV risk’.  One reference is a study about snus and the other reference explores the use of e-hookah in a single session compared to hookah use in a single session, among hookah users.

“There are multiple instances where the authors use irrelevant citations to support their claims (e.g. stating that passive/second-hand vaping causes harm without citing any studies exploring this) or make misleading claims (e.g. one vape being equivalent to smoking 20 cigarettes). This may be a referencing issue that could be corrected, but they also claimed that the evidence was ‘unequivocal’ and ‘consistent’ when they have simply failed to mention the evidence that did not support their stance. The first author has previously cited these studies in other publications, so I can’t imagine why they have omitted them here. Much of the evidence that they do provide refers to the effects of smoking and passive smoking rather than other nicotine products.

“Some of the recommendations did not reflect the statements made in the review: e.g. the authors said that the effect of nicotine is not dose-dependent, but then called for a tax on nicotine products that is proportionate to the amount of nicotine in the product. They also call to ban flavours in nicotine products. Flavours were available in vapes for years before young people started using them in the UK, and they are already accessing products through illegal routes, so banning them is unlikely to stop use. The authors do not provide any evidence that banning flavours will reduce cardiovascular harm either by being effective in reducing vaping (without increasing use of illicit markets or encouraging other nicotine product use) or by reducing exposure to harmful chemicals.

“The authors also state that e-cigarettes are not effective for quitting smoking (while showing evidence that they are!) – simply because many people continue to vape. This is not a logical statement! E-cigarettes may not be effective for quitting nicotine in a short timeframe (less than one year), but they are clearly effective for stopping smoking – and that’s the most important thing.

“Finally, it should be noted that some authors have previously received funding from pharmaceutical companies who sell cessation medications that do not contain nicotine (e.g. varenicline). This could be considered a competing interest as the authors are discouraging the use of nicotine products to stop smoking and encouraging the use of other medicines.”

Prof Peter Hajek, Professor of Clinical Psychology and Director of the Health and Lifestyle Research Unit, Queen Mary University of London (QMUL), said:

“There is much factually wrong with this report.  In my view this is not a scientific review, but an effort to persuade European regulators to clamp down on any nicotine products like vapes and pouches that do not have pharmaceutical licensing.  The main glaring problem is that the authors fail to acknowledge the extensive and clear evidence that vapes and pouches are far less harmful than smoking. 

“The article and the press release give the impression that vaping or pouches pose the same risks to the heart and blood vessels as smoking. This is not true.  Without everything else you get from burning tobacco, nicotine poses only a small fraction of the risks of smoking to the heart and blood vessels.  Switching from smoking to ‘snus’, Swedish oral tobacco that delivers more nicotine than cigarettes, practically eliminates smoking-related risks of heart attacks and atherosclerosis.   

“The section titled ‘Nicotine as a cardiovascular toxin regardless of delivery method’ even gives as its main source a high quality scientific review of cardiovascular effects of nicotine that came to the opposite conclusion: that ‘risks of nicotine without tobacco combustion products are low compared cigarette smoking’ and that ‘electronic cigarettes appear to pose low-cardiovascular risk’. 

“The article and the press release make other claims that contradict evidence, e.g. that vaping is a gateway into cigarette smoking (when in fact vaping is replacing smoking), that vapes do not help smokers quit (they do), that there is a growing vaping epidemic among youth in the US (vaping in youth declined substantially since 2019).  

“Switching from smoking to vaping or pouch use can help smokers to avoid not only heart disease, but also lung disease and cancer. My concern is that if smokers get the false impression that smoking/vaping/pouches all pose the same risks, it will further discourage them from making the switch.”

‘Nicotine and the cardiovascular system: unmasking a global public health threat’ by first author et al. was published in the European Heart Journal at 00.05 UK time on Thursday 18 December 2025. 

DOI: https://doi.org/10.1093/eurheartj/ehaf1010

Declared interests

Peter Hajek: “No COI”

Jasmine Khouja: “I have no conflicts of interest to declare.”