Apoptosis is important in normal development as well as in diseases such as atherosclerosis. However, the regulation of apoptosis is still not completely understood. We now show that the transcription factor nuclear factor-kappaB (NF-kappaB) controls the induction of apoptosis in human and rat vascular smooth muscle cells (SMCs). SMCs in high-density culture exhibited a high NF-kappaB activity and were insensitive to induction of apoptosis. Inhibition of NF-kappaB by adenovirus-mediated overexpression of its inhibitor IkappaBalpha caused a marked increase in cell death at low but not high cell density. Elevating endogenous IkappaBalpha levels by inhibiting its degradation with proteasomal inhibitors resulted in induction of apoptosis in low-density SMCs, as detected by increased binding of annexin V, reduced mitochondrial membrane potential, and increased hypodiploid DNA. In high-density cultures, protection against apoptosis was associated with the expression of inhibitor of apoptosis protein-1 (IAP-1). Transfer of IkappaBalpha reduced human IAP-1 mRNA levels, which suggested that IAP-1 is transcriptionally regulated by NF-kappaB. This was confirmed through identification of a motif with NF-kappaB-like binding activity in the human IAP-1 promoter region. Moreover, antisense inhibition of IAP-1 sensitized high-density SMCs to the induction of cell death. Together, our data imply that SMCs at high density are protected by an antiapoptotic mechanism that involves increased expression of NF-kappaB and IAP-1. Interference with pathways that control the susceptibility to programmed cell death may be helpful in the treatment of diseases where dysregulation of apoptosis is involved, eg, atherosclerosis and restenosis.