The policy brief Nicotine and Cardiovascular Health: When Poison is Addictive summarizes the latest evidence on nicotine and heart health. It aims to raise awareness of the dangers associated with nicotine use, allowing readers to make informed decisions with regard to both traditional and newer tobacco and nicotine products.
The policy brief aims to provide guidance to a wide range of stakeholders, including the general public, healthcare professionals, researchers, policymakers, the tobacco control community, the global cardiovascular community, the global health community, civil society organizations, and governments.
Nicotine is universally recognized as the primary addictive component fuelling the continued use of tobacco products, which are responsible for over 8 million deaths every year. The toxic compounds found in tobacco smoke and tar are generally cited as the main culprits behind the cardiovascular and respiratory diseases, as well as cancers, associated with tobacco use. However, the harmful effects of nicotine are frequently disregarded.
The tobacco industry has propagated the myth that nicotine is “as harmless as caffeine” for decades in order to promote its newer tobacco and nicotine products, prioritizing profits over human lives. In light of continued industry misinformation, further heightened by vested commercial interests, our policy brief reviews the latest scientific evidence to raise awareness of the potential harmful effects of nicotine on the cardiovascular system and outlines a set of measures that stakeholders can implement to safeguard both individual and public health.
Nicotine is a highly toxic and addictive substance naturally found in the leaves of tobacco plants such as Nicotiana tabacum or Nicotiana rustica. Nicotine can be absorbed via sublingual, buccal, intranasal, inhalational, and transdermal routes. Tobacco farmers may typically suffer from green tobacco sickness, a form of nicotine poisoning resulting from handling tobacco plants.
Aggressive marketing strategies, as well as misleading claims by manufacturers, have largely contributed to the belief that nicotine is fairly harmless. However, evidence shows that nicotine is far from innocuous, even on its own. In fact, a myriad of studies has described its adverse effects on cardiovascular and respiratory health, various cancers, and brain maturation.
Nicotine is naturally present, in infinitesimal concentrations, in several edible plants of the nightshade family, which includes tomatoes, eggplants, and potatoes. However, one would need to consume several hundreds of potatoes to match the nicotine concentrations found in a single cigarette.
Research indicates that acute nicotine consumption leads to temporary elevations in heart rate, vascular tone, and blood pressure. Evidence also suggests that chronic nicotine use is associated with accelerated atherosclerosis, coronary heart disease, congestive heart failure, cardiac dysrhythmias, and thrombosis.
Studies indicate that nicotine consumption is correlated with increased risks of respiratory diseases, gastrointestinal disorders, and cancer. Data suggest that exposure to nicotine also affects reproductive health as well as brain development in children and adolescents.
Nicotine is a highly potent drug, confirmed to be as addictive as cocaine or heroin, and remains a common denominator in all tobacco and nicotine products. A hallmark of nicotine dependence is an inability to control its use, which can generally be observed in failed attempts to quit.
Recreational tobacco and nicotine products deliver nicotine in doses and profiles that are able to initiate and maintain dependence. Data indicate that most smokers would not use tobacco products, if not for nicotine.
A growing body of evidence indicates that Electronic Nicotine Delivery Systems (ENDS), also commonly referred to as e-cigarettes, and Heated Tobacco Products (HTP) are far from innocuous. In fact, numerous studies suggest that e-cigarettes and HTP are associated with increased risks of cardiovascular and other health harms.
While e-cigarettes and HTPs emit lower concentrations of some toxicants when compared to conventional cigarettes, the dose-response relationship between these harmful substances and cardiovascular disease may not be linear. Modern e-cigarettes are able to generate similar levels of carbonyl compounds and particulate matters as traditional cigarettes.
Newer tobacco and nicotine products also introduce new toxic compounds that are not found in conventional cigarettes (e.g., flavouring agents that may be safe for ingestion, but not for inhalation, etc.). Further research is needed to evaluate the long-term safety and adverse effects of these products on human health.
E-cigarettes and HTPs have demonstrated limited effectiveness as tobacco cessation tools in real-world settings, despite being advertised as such. On the contrary, many studies suggest that e-cigarettes and HTPs are gateways to conventional cigarettes. As of 2023, no e-cigarettes or HTP manufacturers have officially registered their products as smoking cessation aids with relevant national health agencies.
Nicotine Replacement Therapies (NRT) are first-line medications for the treatment and management of tobacco dependence. They are designed to deliver nicotine in safe and effective doses and profiles through established protocols (i.e., posology, etc.) to achieve tobacco cessation.
In contrast to e-cigarettes, the long-term safety of NRTs is well documented. NRTs do not expose users to additional toxicants and deliver nicotine in profiles that minimize abuse liability.
NRTs are official medications approved by most national drug agencies and endorsed by the World Health Organization. The efficacy and effectiveness of NRTs have been confirmed through rigorous clinical trials. In addition, the content and formulation of NRTs are also strictly regulated by relevant health authorities. NRTs are designed to deliver nicotine in slow and progressive manners which minimize potential for abuse.
In contrast, recreational tobacco and nicotine products do not adhere to the same standards. The ingredients and nicotine concentrations in recreational products are loosely regulated. The safety, addictive potential, and health effects of these products have not yet been adequately studied.
Misinformation
The tobacco industry actively and publicly denied the addictive nature of nicotine until the early 2000s. Nowadays, its strategy has shifted to spread the myth that nicotine is as harmless as caffeine in order to lobby for minimal regulations and maximise profits of its newer products.
Risk-Reduction Discourse
The tobacco industry has been promoting its newer tobacco and nicotine products as significantly less harmful than conventional cigarettes and/or as tobacco cessation tools. However, no long-term studies exist to support these advertised positive health claims.
Synthetic Nicotine
Nicotine has been traditionally extracted from tobacco plants for economic reasons. However, manufacturers have sought to synthesize nicotine chemically in order to exploit loopholes in existing tobacco control policies. The tobacco industry has purposefully labelled synthetic nicotine as tobacco-free nicotine in an effort to misleadingly promote it as cleaner, purer, and safer than tobacco-derived nicotine.
Published: 15 November 2023