Nicotine, regardless of the delivery system, is a “potent cardiovascular toxin,” states a recent report, calling for urgent action from the European Union to clamp down on its use.
The “expert consensus report” was published in the European Heart Journal in December. A bombastic accompanying press release from the European Society of Cardiology declared, “Vapes, pouches, heated tobacco, shisha, cigarettes: nicotine in all forms is toxic to the heart and blood vessels.”
“The narrative of ‘safer nicotine’ must end.”
It quotes one of the report’s authors, Professor Thomas Münzel of University Medical Centre in Mainz, Germany, as stating: “The narrative of ‘safer nicotine’ must end.”
Presumably, it would be replaced by a narrative that all forms of nicotine use—from the cigarettes that cost millions of lives each year to harm reduction alternatives right through to NRT—are equally risky.
“Nicotine is not a harmless stimulant; it is a direct cardiovascular toxin,” Münzel said. “Our findings show that nicotine itself, even without the multitude of toxic combustion products, tar, or free radicals present in cigarette smoke, drives cardiovascular damage.”
Referring to adolescent use, he warned that without tighter controls, “we risk losing an entire generation to nicotine addiction.”
The authors call for a range of measures to be introduced across Europe, including flavor bans for all nicotine products, taxation that is “proportional to nicotine content,” and other restrictions on use, sales and advertising.
But the report has drawn fierce criticism from health professionals and scientists, who have attacked both the validity of its findings and its explicit policy goals.
“This article is not a scientific study,” said Dr. Jasmine Khouja, a psychologist at the University of Bath in England, in one critique; “the four experts in cardiology who wrote it describe it as an expert review, but no experts in vaping or nicotine research were included.”
She noted the report’s “strong claims that are backed by no/limited evidence or have contradictory evidence that is not discussed,” and “multiple instances where the authors use irrelevant citations to support their claims … or make misleading claims.”
“The authors’ slogan of ‘one message, one risk’ represents a failure in health communication.”
Dr. Konstantinos Farsalinos is himself a cardiologist, and a research associate at the University of Patras and the University of West Attica in Greece.
“The authors’ slogan of ‘one message, one risk’ represents a failure in health communication,” he told Filter. “While nicotine is not risk-free, there is an undeniable continuum of risk, with a massive gap” between combustibles and safer alternatives.
The clear risk of such messaging, he said, is that people who smoke will be misled into believing there is no benefit in switching to safer, potentially life-saving alternatives.
The report, Farsalinos continued, attributes health threats to nicotine based largely on acute physiological markers, while ignoring extensive epidemiological evidence.
Among other examples, he pointed to a study from South Korea that followed 18,000 people who smoked and had undergone percutaneous coronary intervention, and who variously continued smoking, switched to vapes or quit nicotine entirely. Those who switched and those who quit saw similar reduction in their risk of Major Adverse Cardiac Events (MACE) in the following years.
Sweden, a country that has embraced snus and nicotine pouches as safer alternatives to cigarettes, giving it the world’s lowest smoking rate, is another case in point. Its population offers no evidence that nicotine, without the combustion, equates to poor cardiovascular health.
Dr. Polosa was “shocked” that the report failed to address “strong epidemiological evidence” around Swedish snus from large cohort studies.
“The Swedish cohort data do not support the fantasy that nicotine in oral products produces the [same] cardiovascular profile as tobacco smoking,” Dr. Riccardo Polosa, professor of internal medicine at the University of Catania, Italy, told Filter.
He added that he was “shocked” that the recent report failed to address “strong epidemiological evidence” around Swedish snus, derived from large cohort studies.
“After adjustment for confounders, oral nicotine use was not associated with myocardial infarction, heart failure, atrial fibrillation, or cardiovascular mortality,” he said, “highlighting the importance of combustion versus nicotine per se.”
Needless to say, Farsalinos is no fan of the report’s policy recommendations either.
“The fact that lethal cigarettes are sold legally across Europe while their far lower-risk alternative, snus, is banned [in the EU, except Sweden] is not a regulatory success—it is a public health scandal,” he said. “Demonizing nicotine is scientifically unjustified and serves only to perpetuate the smoking epidemic.”
On that note, the report even attributes “vascular harm” to passive vaping.
In 2025 Europe became the continent with the highest smoking rate, according to the World Health Organization, at 24.1 percent. But to Münzel and his co-authors, the threat comes from elsewhere.
“The next heart attack, the next stroke, the next cardiovascular death may not come from a cigarette, but from a flavoured pod, a nicotine pouch, or a waterpipe in a café,” he said in the press release. “If Europe fails to act now, we will face the largest nicotine addiction wave since the 1950s.”
European advocate Damian Sweeney sees the report’s policy agenda against safer nicotine products as deliberately timed.
Damian Sweeney, an Irish advocate and partner with the consumer advocacy group European Tobacco Harm Reduction Advocates (ETHRA), sees the report’s policy agenda against safer nicotine products as deliberately timed.
“It’s not a coincidence that this report, which is essentially an opinion piece masquerading as an evidence-based scientific report, was published just a few days after the adoption of the EU Cardiovascular Health Plan,” he told Filter.
ETHRA participated in the call for evidence for that plan, regarding the cardiovascular implications of tobacco and nicotine use and the benefits of switching to smoke-free alternatives, but was disappointed by the outcome.
“Both documents fail to acknowledge the relative risk of nicotine products, and [that] the harms to heart health are due to toxic byproducts of combustion, not merely using a nicotine product,” Sweeney said.
He dismissed the European Heart Journal report as “little more than a lobbying document” seeking to influence the upcoming revision of the Tobacco Products Directive, which places limits on the sale and merchandising of tobacco and related products in the EU. Proposals from the European Commission are expected at the end of 2026.
Other relevant situations that the report could be looking to sway include the European Parliament working on its cardiovascular diseases strategy, with discussion ongoing in the SANT Committee on public heath. A proposal for a revised taxation directive was also published in July, Sweeney noted, and is now being discussed by EU member states.
In stark contrast to the report, Farsalinos said, “harm reduction has been proven as an essential tool if we want to accelerate the decline in population smoking rates.”
Photograph (cropped) by Madison Oren on Unsplash
The Influence Foundation, which operates Filter, formerly received grants from Global Action to End Smoking and Juul. Dr. Polosa founded the Center of Excellence for the Acceleration of Harm Reduction, which has received grants from Global Action to End Smoking, and Dr. Farsalinos received a consulting fee from Juul in 2018. Filter‘s Editorial Independence Policy applies.
