I recall there’s a few things. Pardon me for replying in this thread instead:
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Enemies are tougher to kill. They are not shown on radar either.
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Tommy’s health is weaker, so is the effect of replenishing it via a drug cabinet. You will only gain a quarter of the health bar.
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Timers on mission are more restricted.
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Traffic law is presented, and police’s reaction becomes more realistic. It means you will attract police attention from speeding and running red light.
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You can still freely adjust car handling, with default setting being ‘realistic.’
That’s all, I think. If I miss or get wrong about anything, let me know. 