Do Next Generation Nicotine Products Reduce Cardiovascular Risk?

Introduction

Cigarettes remain one of the biggest preventable causes of heart disease globally. At the centre of this harm is a single key factor: smoking cigarettes.

Smoking is a cause of serious disease in smokers, including heart disease. Science demonstrates the smoke created by burning tobacco damages the lining of blood vessels, triggers inflammation, and contributes to the gradual build-up of fatty plaques in arteries, increasing the risks of illnesses like heart attacks and strokes.

The emergence of next generation nicotine-containing products (NGP) like vapes, nicotine pouches, and heated tobacco means nicotine can now be consumed without combustion, raising a crucial public health question:

If you remove the smoke, can you reduce the harm?

Our new comprehensive narrative review of the literature focuses on the potential cardiovascular health impacts of NGP. This review contains over 200 references drawn from diverse fields, including laboratory science, clinical trials, epidemiology and population studies, plus regulatory documents.

Here’s What We Discovered

The good news is that different types of research point towards the same promising conclusions for NGP.

In the Lab…[i]

When scientists test NGP on cardiovascular cells (in-vitro) they find:

  • NGP cause less damage, and trigger less inflammation and oxidative stress in blood vessels compared to cigarette smoke.
  • Using NGP instead of smoking helps lowers the risk of early changes linked to plaque build-up which can contribute to heart diseases like arteriosclerosis.

Animal studies broadly back these findings up, demonstrating less arterial damage by NGP aerosol compared to cigarette smoke.

In the Clinic…[ii]

When adults who smoke switch to NGP, two important events often occur:

  1. Exposure to harmful chemicals drops sharply
    Levels of harmful chemicals linked to heart disease – including carbon monoxide and certain aldehydes – drop significantly, often close to levels observed when people stop smoking entirely.
  2. Cardiovascular health-related biomarkers improve
    The weight-of-evidence across many studies shows:
  • Lower levels of inflammation.
  • Reduced biomarkers linked to potentially harmful blood clotting.
  • Improvements in some cholesterol measures.

These are admittedly early indicators, but they closely align with what we know about how heart disease develops, and are therefore positive signs of the cardiovascular harm reduction potential of NGP compared to smoking.

In Wider Populations…[iii]

Focusing on large, real-world studies:

  • People who fully switch away from cigarettes to NGP tend to have a lower cardiovascular risk than those who continue smoking.
  • There’s no clear evidence of increased heart risk in people who have never smoked, but who still use NGP.
  • Dual users (i.e. individuals who smoke and use NGP) don’t experience the same health gains as those who fully switch – but it’s important to bear in mind that for many adults who smoke switching is a process that can help reduce cigarette consumption while supporting a gradual transition to NGP, increasing the likelihood of eventually stopping smoking altogether.

Are there any Data Gaps?

The overall picture painted by our narrative review is encouraging, but many stakeholders – including regulators and public health bodies – will likely require more data before a complete picture can be established.

For instance:

  • Most of the research published in the academic literature to-date focuses on short‑ to medium-term studies, not longer term outcomes.
  • This is especially true for newer NGP categories like oral nicotine pouches – though the epidemiological outcomes of widespread tobacco snus use in Sweden in place of smoking suggests this similar category has significant public health potential.

People’s previous smoking habits can undoubtedly influence results

There needs to be more, and more robust, monitoring and reporting of real-world NGP usage patterns.

As with all narrative reviews, the evidence base continues to evolve, and ongoing research remains vitally important – which Imperial remains committed to contributing to through our multidisciplinary scientific assessment framework.

Conclusion

Across laboratory studies, clinical trials and population data, the message is broadly consistent and extremely encouraging for NGP:

  • The biggest driver of cardiovascular harm is exposure to the many harmful chemicals in the smoke created from burning tobacco.
  •  NGP have the potential to significantly reduce exposure to these chemicals.
  • People who move away from cigarettes – especially those who fully switch i.e. exclusively use NGP – show clear signs of reduced cardiovascular risk.

It’s important to note that NGP should be designed for, and marketed towards, existing adults who smoke and nicotine consumers only; they’ re not risk-free, and the best option remains quitting nicotine entirely.

But for adults who continue to smoke, NGP offer something vitally important:

A potentially less harmful smoking alternative, and a path away from cigarettes.

The graphic above shows how the findings of our latest review align with the stances of notable health bodies.

Written by Rob Taylor, Senior Harm Reduction Communications Manager.

Sources

[i] Chapman F, de Haan L, Gijzen L, et al.: Optimisation of an in vitro human cardiovascular model on-a-chip for toxicological assessment of nicotine delivery products. Front Toxicol. 2024, 6:1395670. 10.3389/ftox.2024.1395670;

Ohashi K, Hayashida A, Nozawa A, Matsumura K, Ito S: Human vasculature-on-a-chip with macrophage-mediated endothelial activation: the biological effect of aerosol from heated tobacco products on monocyte adhesion. Toxicol In Vitro. 2023, 89:105582. 10.1016/j.tiv.2023.105582

[ii] D’Ruiz CD, Graff DW, Robinson E: Reductions in biomarkers of exposure, impacts on smoking urge and assessment of product use and tolerability in adult smokers following partial or complete substitution of cigarettes with electronic cigarettes. BMC Public Health. 2016, 16:543. 10.1186/s12889-016-3236-1;

Gale N, McEwan M, Hardie G, Proctor CJ, Murphy J: Changes in biomarkers of exposure and biomarkers of potential harm after 360 days in smokers who either continue to smoke, switch to a tobacco heating product or quit smoking. Intern Emerg Med. 2022, 17:2017-30. 10.1007/s11739-022-03062-1

Roethig HJ, Feng S, Liang Q, Liu J, Rees WA, Zedler BK: A 12-month, randomized, controlled study to evaluate exposure and cardiovascular risk factors in adult smokers switching from conventional cigarettes to a second-generation electrically heated cigarette smoking system. J Clin Pharmacol. 2008, 48:580-91. 10.1177/0091270008315316

[iii] Stokes AC, Xie W, Wilson AE, et al.: Association of cigarette and electronic cigarette use patterns with levels of inflammatory and oxidative stress biomarkers among US adults: Population Assessment of Tobacco and Health study. Circulation. 2021, 143:869-71. 10.1161/CIRCULATIONAHA.120.051551

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