Community-Level Wastewater Surveillance of Nicotine Biomarkers Tracks Cardiovascular Disease Burden and Myocardial Infarction
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BACKGROUND
Tobacco smoking is the largest modifiable contributor to cardiovascular disease (CVD), yet population-level surveillance still relies on self-reported and retail data, which are subject to measuring bias and lag. Urinary and salivary cotinine quantify individual tobacco exposure, but no analogous, objective metric exists at the community level. Wastewater-based epidemiology (WBE) has transformed surveillance of infectious diseases and illicit drug use; whether the same approach can yield a community-level signal of CVD risk is unknown.
OBJECTIVE
The primary objective of this study is to track community-level wastewater nicotine biomarkers and evaluate potential correlations with relative CVD burden in El Paso, Texas.
METHODS
We integrated wastewater nicotine biomarker surveillance with electronic health record (EHR) data across four sewersheds in El Paso, Texas. Twenty-four-hour composite influent samples were collected monthly (June 2024–May 2025; n=48) and quantified by liquid-chromatography tandem mass spectrometry for five nicotine metabolites. Cotinine, nornicotine, and trans-3’-hydroxycotinine (3HC) were detected in 91.6–100% of samples, whereas tobacco-specific nitrosamines were below limit of detection. CVD cases (January 2021–December 2024) were obtained from the Paso del Norte Health Information Exchange and mapped to sewersheds by residential ZIP code using ArcGIS. At the sewershed level, population-normalized nicotine mass loads tracked the proportional burden of atherosclerosis/ischemia/infarction and heart failure. Across the sewersheds, monthly 3HC mass load and the nicotine metabolite ratio (NMR) were strongly and specifically associated with incident ST-elevation myocardial infarction (STEMI) (3HC vs. STEMI: ρ = 0.893, p = 0.012), without parallel associations for non-ST-elevation or old myocardial infarction.
CONCLUSIONS
To our knowledge, this is the first demonstration that integrating wastewater nicotine surveillance with EHR data can reveal community-level 3HC and NMR as specific indicators of incident STEMI. Our findings indicate wastewater surveillance as a novel, objective tool to inform cessation policy and CVD prevention.
Lay Words
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This study investigated using wastewater to measure population-level nicotine consumption and to see if it was related to local cardiovascular disease.
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The study took place in El Paso, Texas, USA across 4 different wastewater treatment collection points over the course of one year.
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Three metabolites of human nicotine consumption were detected in wastewater samples. The increased nicotine mass loads were proportional with community-level heart failure and atherosclerosis.
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Wastewater can be a helpful tool to inform cardiovascular disease prevention efforts and smoking cessation practices.
