What does the current evidence tell us about the cardiovascular impact of novel tobacco and nicotine products?
In this presentation from Global Forum on Nicotine 2026, Dr. Thomas Nahde discusses a narrative review examining cardiovascular health and the potential impact of switching from combustible cigarettes to non-combustible nicotine products.
The review brings together 221 publications, covering experimental research, clinical studies and population-level evidence. It examines cardiovascular toxicant exposure, biomarkers of potential harm, atherosclerosis-related mechanisms, and evidence surrounding e-cigarettes, heated tobacco products and nicotine pouches.
Transcription:
GFN Science Lab 3 — Thomas Nahde
2026-06-05 · 11:30-13:00 (Europe/Warsaw) · Global Forum on Nicotine 2026
Sud Patwardhan 0:00:11
Dr. Thomas Nahde's presentation is the last presentation, please. Let's watch that.
Matthew Stevenson 0:00:16
Hello, my name is Matthew Stevenson. And today I'll be presenting a narrative review examining the potential impact of novel tobacco and nicotine products on cardiovascular health. Here is my conflict of interest statement. As a responsible manufacturer, Imperial Brands applies a multistage, multidisciplinary scientific assessment framework, or SAF.
The SAF supports evidence-based assessment of product safety and substantiates the tobacco harm reduction potential of our next generation products, which includes post-market surveillance of the published scientific literature. The review I'm presenting today sits firmly within that approach.
Whilst the risks of smoking on the cardiovascular system are well known, the cardiovascular impacts of novel tobacco and nicotine products are often discussed in a fragmented and inconsistent way.
Our aim of this review was to integrate mechanistic, clinical and population-level data to assess whether switching from cigarettes meaningfully reduces cardiovascular risk and to inform evidence-based harm reduction discussions.
This narrative review covered 221 publications and focused on four key areas, including in vitro and in vivo cardiovascular disease models, human clinical studies, population level assessments, and finally, how regulators are evaluating cardiovascular risk. However, due to time constraints, this is out of scope of today's presentation.
I should note that this review is currently undergoing journal submission and review. Cigarette smoking is a cause of serious disease in smokers, including cardiovascular disease.
Atherosclerosis is reportedly responsible for the development of most cardiovascular diseases and develops through a pathway of endothelial dysfunction, lipid infiltration, macrophage recruitment, and vascular remodeling. Smoking was reported to be responsible for one in every four deaths in the United States from cardiovascular disease.
and smokers are reportedly two to five times more likely to experience both fatal and non-fatal cardiovascular disease events than non-smokers. While the level of cigarette consumption may influence the degree of cardiovascular risk, even low levels of cigarette smoking significantly elevate the likelihood of development of cardiovascular disease.
Evidence from the reviewed in vitro studies consistently show that evapour and heated tobacco product aerosols are far less cytotoxic than cigarette smoke. We see reduced endothelial damage, improved wound healing, lower inflammatory signalling and reduced oxidative stress, all key drivers of atherosclerosis.
In in vivo mouse models, cigarette smoke markedly increases plaque burden and cardiovascular dysfunction. By contrast, exposure to evapour or heated tobacco product aerosols results in substantially lower plaque development, often comparable to smoking cessation or switching groups.
Turning to clinical trials, smokers who transition to evapour products, heated tobacco or nicotine pouches show marked reductions in exposure to key cardiovascular toxicants. In many studies, biomarker levels approach those seen in abstainers or never smokers, demonstrating a substantial reduction in toxicant exposure when cigarettes are displaced.
Beyond exposure, we also see improvements in biomarkers of potential harm within 3 to 12 months of switching. These include reductions in inflammatory markers, platelet activation, and oxidative stress, alongside improvements in lipid profiles. Importantly, these improvements are often similar to those observed with smoking cessation.
At the population level, most evidence comes from surveys conducted in the United States, which are largely cross-sectional in nature and are prone to clear limitations around confounding and disease timing.
However, when smoking history and temporality are properly accounted for, exclusive evapour use is not associated with increased cardiovascular risk, and is consistently associated with lower risk than continued smoking. Emerging data from heated tobacco product populations, particularly in Japan and South Korea, also suggest harm reversal relative to smoking.
However, key evidence gaps remain, especially for long-term health outcomes and oral nicotine pouches. In conclusion, we observe strong convergence of evidence across experimental, clinical, and epidemiological studies.
Exclusive switching to next-generation products reduces exposure to cardiovascular toxicants, improves biomarkers of cardiovascular health, and lowers cardiovascular risk compared with continued smoking. The key message is that supporting complete displacement of cigarettes with novel nicotine products has the potential to substantially reduce cardiovascular disease burden.
These findings reinforce the potential role of next-generation products in tobacco harm reduction, and Imperial Brands remains committed to advancing robust science in support of evidence-based proportionate regulation.
Before closing, I'd like to thank everyone involved in this work, and I'd like to thank you for your attention.
Sud Patwardhan 0:05:57
Just to say that that was not Thomas Nahde with a beard on. But why don't we open this for questions for you specifically, Thomas, and then we can open it for the rest of the panel, please. Any specific questions for this presentation? Hmm. I am tempted to ask something.
I actually took a picture of that, because it was quite interesting to see in that last slide, or one of the last slides you had. Let me read that, because I don't want to make it up.
You talked about evidence gaps, and I think that also fits in well with the question that was asked earlier regarding modern oral products, and that was mentioned in your review that there are some gaps there in terms of the effect of modern oral products on cardiovascular health. My question is, why would there be a concern, and would it be around nicotine or something else?
Thomas Nahde 0:06:53
Well, that is a really good question. Maybe let me come up with a couple of housekeeping comments first. First of all, I'm not, as you said, Matt Stevenson, but I want to acknowledge that because I'm representing here for the group of authors, right?
And the group of authors is including Matt Stevenson, who is the corresponding author, but I'm very happy to also have the first author, Ian Viron, here in the audience. And I'm probably directing any of the difficult questions to you, Ian, on that one. So on your question, I think there is a way more general point because you're pointing to the available gaps.
But I think the broader question is overall, why do we need another review on that?
Because I think if we look into the audience, and I would say that probably the majority, if not all, and everyone in the audience would probably say and agree, and I know that Mark Tyndall always said, you need to be more bold, but let me be more careful there, that the weight of evidence is indicative of a differential risk between combustible and non-combustible products in relation to cardiovascular risk, right?
So the point is, at the time when we conceptualized this review, Europe was, and I think still is, facing a policy moment where the language around these different risks is about to shape the regulation of these products for the years to come, right?
And if we fail to actually explain and be clear about those differential risks, right, then we risk that the regulation of these products in the future will be built on emotions or beliefs or at least on misinterpreted science, right?
Hence why we really wanted to contribute to the conversation with a review on the totality of the signs, what we believe was the totality of the signs, actually really looking into what is the sign saying if adults who smoke completely switch away from smoking to NGP, right?
So what we did is, and we looked into, well, probably not the 200 plus publications, because some of those were background, but I think 160-ish, something of that.
And that ranged from very simple, easy, in vitro tests, like scratch wound assays, right away over to more complex models, organ on a chip, animal models, over and into randomized controlled studies, and then into actually population available data. And then we really want to triangulate that data and really get a totality of the picture.
And I think what the totality was indicating was, and that was pretty, pretty consistent across all of that, was that if Smoke is switched to non-combustible products. That is associated with reduced biomarkers. And we have seen that in your data, right?
Reduced biomarkers of exposure, reduced biomarkers of harm, and actually an overall improvement of cardiovascular measures and indicators. But what we also wanted to do is be very open around the limitations of the signs and the caveats that we found.
And just to mention a few, and we were very open and honest on that, so it is about to be published, and we encourage you to read it and look into that one. So I think number one is dolius. still preserves cardiovascular risk, right? And honestly, that's not really surprising because smokers are still exposed then to the toxicants from the combustion.
Number two was, and that was maybe a little bit of a surprise, that, but maybe not so much of a surprise because we exactly see the same now happening with the EUTPD consultation process.
If you want to honestly assess the risk, you need to do more than just talk about the appearance of the toxicants and the sheer presence of those, because that's more like a hazard analysis, you need to take into consideration the level of the exposure, right?
And the third one, and that gets a bit more tricky, is really when you talk about, and we saw a lot of those and we were all highlighting those, the caveats around study design and the confounders and temporality and causation, reverse causation and all of those things. So to quickly answer that, really contribute to that conversation.
And I think the more data we gather on that, the more reviews that come up and have a conversation about that, I think the more helpful it is.
Sud Patwardhan 0:12:16
Thank you so much for the very comprehensive but very thorough answer. I appreciate you doing that. And also I understand that Although everyone would love to have emotion to decide whatever they want to do on their daily preferences, for policymaking, it has to be evidence-led. And I hope you submit that as part of the EU process as well, what comes out of that.
If there is no question about this presentation, I do want to... Is it for this presentation, Rasmus? No. In that case, there was a question by Philippe first, which we want to answer about oral cancer and snus, specifically, or... Yeah, but let's deal with that because I promised you that. And the doctor from Libya as well about all these products, HTPs, EVPs and so on.
So I want to open it for all of them.
Thomas Nahde 0:13:03
Maybe just answering your direct question on the appetite also on longer term studies around cardiovascular health. It's an absolutely fair and relevant question on that, right? To the point, I would say a lot is already available.
But I honestly believe after that review, before we move into any longer-term studies, let's say, I don't know what you're thinking of, two years, five years, whatever that, right? Because that is a, for anyone who would conduct that study, massive investment, right?
What we need to get right, because that was coming out of that review, is we need to get the standardization right.
We need to get a common understanding of how we define things, what do we understand by about dual use and things, what do we understand about a former user, current user, dual use, how do we define all of that, and honestly also get a proper understanding and agreement, ideally by a larger group of people conducting that studies, what are the right indicators we are looking into, what are the right cardiovascular measures, because if we think about very recently a number of reviews have been published on exactly the same topic, Very different scopes on that.
All relevant, I would say. Some of them were actually looking into clinically validated measures of cardiovascular health like FMD, pulse wave velocity, and augmentation index. So you need to really understand what do you want to measure and then to agree on Is that the right measure that we want to look into?
Because we have seen all of that, very different study designs and very different actually definitions, which then is about to blur at least the outcome and to blur the evidence, and then it's messing it all up.
Sud Patwardhan 0:15:04
So Leonie, may I put you on the spot and say, do you want to answer any of the two questions earlier about HTPs specifically? Because you're the only one who presented HTPs as such. And long-term studies regarding heated tobacco products. That may hopefully answer the doctor's question. And also, if you want to have a go at the oral cancer snooze thing, have a go.
Leonie Price 0:15:21
Why not? Why not? Let's go for it.
Sud Patwardhan 0:15:23
But look, I'm conscious before you start answering. We have 11 minutes. I like to close things on time. So not more than a minute and a half for each answer. Perfect.
Leonie Price 0:15:30
I think my biggest surprise of today actually is the preference for banana, but we can talk about that later. There are some really good population studies which are looking at cardiovascular disease risk. And I think particularly in Korea and Japan that we're starting to see data coming out of those big population studies there.
They collect incredibly detailed data sets from patients who are part of health insurance tracking. So we have got a couple of papers coming out with really positive indications on the cardiovascular effect of switching.
and at the moment it seems quite preliminary, but keep your eye on Korea particularly, and keep your eye on Japan because there is some nice data coming out from there. In terms of the snooze and the oral cancer risk, I have not seen any conclusive data to say that there is an association between snooze use and oral cancer. which is counterintuitive, I agree.
Everyone understands that there are some oral changes that happen when people use snooze in the mouth, right? You see oral lesions, but when people quit snooze use, they're reversible, they heal, and actually the long-term oral cancer risk In specifically the Swedish products, let's be clear on that because the oral category is huge.
The Swedish process means that the products are pasteurized and a lot of the TSNAs and the harmful constituents in the tobacco are removed during that manufacturing process of Swedish snus specifically.
So even when you look at traditional smokeless tobacco use in the US, for example, that don't use Swedish snus, you do see differences in the oral cancer risk, even from the US to Sweden. So I think we have to be very specific about the Swedish product. But there's no conclusive evidence there to say that they cause oral cancer.
Sud Patwardhan 0:17:32
Thank you so much. I appreciate you taking that question. So if you're not satisfied with the answer, I would suggest you, thank you. Then you pick up later or after the session. There is Erasmus, but can I have Ian's question first? Because you already asked a question. Sorry.
Ian Fearon 0:17:46
So has Ian, I guess. I'm an independent consultant. It's not so much a question, sir, just as a comment on that point about why do we need to plug that gap of all pouch products and cardiovascular disease? And no sane person would think that pouches would come with some kind of cardiovascular risk. However...
For whatever reason, in the cardiovascular field particularly, we've seen massive misrepresentation of scientific evidence to say that vapes cause strokes or heart attacks and whatever else. And we've seen some high-profile retractions, of course, which is good. But the damage is already done, unfortunately.
And I honestly feel that if we don't plug that gap with pouches, we will begin to see the same thing.
Sud Patwardhan 0:18:33
Absolutely, I appreciate that. Thank you so much for that comment. Anyone wants to add anything or shall I get the next question from Rasmus? Quick question, Rasmus. Did you want to ask a question at all? You're okay.
Rasmus Pagh 0:18:44
No, it's just really a comment to these two gentlemen. Rasmus from Xstimo, independent consultant as well. So if you're really looking for science in a macadam, you can go with this smoke-free Sweden. I don't know if you're familiar with that report, but there's an epidemiological study where you see cancer rates in Sweden over time. And it's not these guys from the industry.
is basically sort of health officials gathering that information. I mean, brilliant presentations, but if you're skeptical about that, there's a brilliant report out there. And you can also look at Karolinska Institute. They've done a lot of studies on snus throughout the years and the course of snus.
There is, I believe, evidence to say or to suggest that oesophagus cancer is higher for snus users, but These are disputed data, but I think there is a lot of good studies out of Sweden. I think the bridge with you meant you referenced one Helen presentation to oral cancer in your one reference there.
There is the challenge in Scandinavia is obviously the consumer data protection. It's not that easy to get data out of the dentists. as you would expect because you're running into sort of a controversy of tapping into the data protection acts of patients, so it's not that easy to get a hold of, but it's something that needs to be explored for sure.
Sud Patwardhan 0:20:21
Thanks, Rasmus, for those comments, and it just means that there's some more research needed, but I think, given we have five minutes, I would like the panel, those who are part of this lab, to have a one-minute kind of, if they want to summarize something, what they have presented or what they've heard you guys ask, and if they want to open it up for you to reach out to them after this session, Should we start in the reverse order and you get the last word, Leonie?
So reverse order, which means Thomas first, then Layla, then Helen, and Leonie. And then I have the last word, sorry.
Thomas Nahde 0:20:54
Maybe this is really a call to action, right? Because I think coming back to my first point and the language around these products, which is currently really about to shape the regulations, right? The consultation process on the EUTPD three, which is about to come, and that has already been opened.
So this is really like, take all the science that is available and make a contribution and really talk about the evidence, which isn't always easy. And as Ian highlighted, and you've highlighted that, specifically when we talk about cross-sectional study.
Well, it's great to have the population data, but that is so tricky to get closer to the truth of that because you have all those confounders and you have the temporality and stuff like that, and then it's so hard to really get to the bottom of the data and really get to the evidence. So, yeah, it's really a call to all scientists in the room and at GFN to make a contribution.
Sud Patwardhan 0:21:50
And the evidence submission date for the call for action is the 15th of June for the science part of it? Yeah, exactly. Okay, I'm sure people have noted that, but yes, as much good quality data is submitted, the better it is for the policy shaping. Layla?
Layla Malt 0:22:05
I think, just to add to Thomas' point about the shaping of regulation, I think I just want to go back to the one size doesn't fit all, and ultimately, we're talking about people, and...
I think it's really important we recognise the harm reduction potential of these products can only be fully recognised if there is access to a range of broad flavours, high quality, responsibly manufactured, responsibly marketed products that these individuals are able to find.
whatever it is within that NGP, next generation product space, that supports that transition for them if they choose to take up an alternative product. And so, yeah, I think I hark Thomas's point around this is the time for us to add our scientific evidence and commentary to support the shaping of the future landscape for those individuals.
Sud Patwardhan 0:23:02
Thank you so much, Layla, for highlighting that this is not for us and our vanity. It's for consumers and their needs for safer products. So thanks for highlighting that. Sorry, Helen, please.
Helen Cowie 0:23:11
Thank you. I think from my perspective, it's really picking up on one of the reports that I mentioned earlier, the WHO's Global Strategy and Action Plan for Oral Health. Within there, they make a statement, which is there is no health without oral health. And I think it was a real recognition of the billions of people who are suffering in the area today.
So from my perspective, I think it's really important that we start to dispel some of the misperceptions that people have around some of the smokeless products versus combustible smoking and that they don't mix up the two because actually healthcare professionals need access to good quality, high quality science really to understand the impact that it can have on somebody's oral health to move away from combustible cigarettes.
And the World Federation of Dentists, for example, actually lump snus in with combustible tobacco when they talk about oral health. But as we've seen from the data, there is a massive difference between somebody taking snus and somebody smoking a combustible tobacco.
if dental health practitioners are not getting accurate data, then they're not able to pass on those recommendations that are based in fact and evidence to consumers around the world and subsequently improve their oral health.
Sud Patwardhan 0:24:41
Thank you so much. My takeaway from this, Helen, is that for next year's GFN for sure, I'm going to ensure that the, or I'm going to advocate for the organizers to have a panel on oral health and dentists should be part of that for sure. Well, thank you so much. Leonie. Thank you.
Leonie Price 0:24:55
I think I'd like to just build on all of those points really and say one of the biggest challenges that we're facing today is misperception and misinformation. And that is at the regulatory level, the policy level, but most importantly at the consumer level.
And how many times have I heard recently people saying, oh, I quit vaping and went back to smoking because they're just as bad? You know, it breaks my heart. And we all have to take a bit of responsibility for making sure that the consumers who are using these products and making that switch fundamentally have access to the right information.
And I think we need to do that across the board.
Sud Patwardhan 0:25:33
Thank you so much. That's very powerful, and I think I want to end with just saying that the very fact that you all have made the effort to represent science that your respective companies are doing with such clarity and transparency is much appreciated. I like the questions that we had from the audience.
I wish we had more people here, but I think we had some very good questions even then. This will be a great way to open some engagement for longer term for you guys and answer questions as honestly as you've done here today. Thank you so much for being here, and thanks for attending.
Leonie Price 0:26:03
Thanks everyone.