Nicotine and the cardiovascular system: unmasking a global public health threat

Nicotine-containing products, whether combustible or smokeless, pose a growing threat to cardiovascular (CV) health. While tobacco smoking continues to cause millions of deaths annually, the rapid uptake of e-cigarettes, heated tobacco, and synthetic nicotine pouches, particularly among the youth, risks reversing decades of progress in tobacco control. In this policy statement, 12 evidence-based key messages that highlight the CV toxicity of nicotine are presented, irrespective of delivery system, and the urgent need for comprehensive regulations. These messages address the vascular and metabolic harms of nicotine, the dangers of passive exposure, the key pathophysiological pathways leading to CV morbidity and mortality, and the economic burden of nicotine-induced CV disease. Importantly, this is the first expert consensus paper to address nicotine itself as a direct CV toxin, independent of combustion. Special attention is given to the paediatric addiction crisis, driven by flavoured products and aggressive marketing, and to the misleading narrative of 'safer nicotine.' This paper appears at a critical regulatory turning point: the European Commission's revised Tobacco Taxation Directive (July 2025), which for the first time introduces minimum excise duties on e-liquids, heated tobacco, and nicotine pouches. While this directive represents an important step, it must be complemented by broader regulations, including advertising bans, flavour restrictions, and indoor-use prohibitions, applied consistently across all nicotine products. Together, the 12 key messages provide a policy blueprint to protect CV health and prevent the rise of a new generation of nicotine-addicted youth.