What are the relative health risks of Mullein vape versus nicotine vape for a patient with pre-existing respiratory conditions?

Avoid Both Mullein and Nicotine Vaping—Neither is Safe for Respiratory Health

For patients with pre-existing respiratory conditions, both mullein vaping and nicotine vaping should be strongly discouraged, as all vaping products pose significant respiratory risks regardless of their contents. While no direct evidence exists comparing mullein to nicotine vaping specifically, the overwhelming guideline consensus is that inhaling any vaporized substance carries substantial pulmonary harm, particularly for those with compromised respiratory systems 1.

Why All Vaping is Harmful for Respiratory Patients

Universal Vaping Risks

• The health risks of electronic cigarettes and vaping products have not been adequately studied, and the addictive power and untoward effects of nicotine should not be underestimated 1.
• Vaping is not without risk, and chronic vaping effects on the respiratory system remain largely unknown 2.
• The Forum of International Respiratory Societies explicitly states that electronic nicotine delivery devices should be restricted or banned until more information about their safety is available 1.

E-Cigarette or Vaping Product-Associated Lung Injury (EVALI)

• Over 2,600 cases and 60 deaths from vaping-associated lung injury have been reported, with patients presenting with fever, cough, shortness of breath, and respiratory distress 1, 3.
• Patients with chronic pulmonary disease (COPD, obstructive sleep apnea) face significantly higher morbidity and mortality from EVALI—70.6% of rehospitalized patients and 83.3% of those who died had chronic conditions, compared to only 25.6% of uncomplicated cases 1.
• Vaping can cause acute eosinophilic pneumonia, diffuse alveolar damage, organizing pneumonia, and lipoid pneumonia 4.

Specific Risks for Pre-Existing Respiratory Conditions

• Comorbidities that compromise cardiopulmonary reserve increase risk for severe disease and disqualify patients from outpatient EVALI management 1.
• Patients with chronic respiratory disease who develop EVALI have median ages of 27 years at rehospitalization versus 23 years for those without complications, indicating even young patients with lung disease face elevated risk 1.
• Up to one-third of hospitalized EVALI patients require mechanical ventilation, with older patients and those with underlying cardiac and pulmonary conditions at highest risk for mortality 3.

Why Mullein Vaping Offers No Safety Advantage

Lack of Evidence for Safety

• No herbal vaping product, including mullein, has been proven safe for inhalation—the absence of nicotine does not eliminate respiratory toxicity from vaporized plant materials and additives 1.
• The act of vaping itself, regardless of substance, produces emissions that can cause second-hand exposure and lung injury 1.
• Vaping devices contain and emit numerous potentially toxic substances beyond nicotine, with exposure highly variable based on product characteristics 5, 6.

Inhalation of Any Vaporized Substance is Problematic

• All vaping products heat and aerosolize substances that are then inhaled deep into the lungs, creating potential for chemical pneumonitis and inflammatory responses 4, 7, 2.
• The 2019 EVALI outbreak highlighted that vaping-related lung injury can occur with various substances, not just nicotine or THC 2, 3.

Clinical Recommendations for Patients with Respiratory Conditions

Absolute Contraindications

• Patients with pre-existing respiratory conditions should avoid ALL vaping products due to their compromised cardiopulmonary reserve 1.
• Healthcare providers should advise individuals to avoid vaping either as a smoking cessation method or for recreational use 8, 5.

Risk Assessment Criteria

Patients with respiratory disease who vape are NOT candidates for outpatient management if they develop symptoms and have:

• O2 saturation <95% on room air 1
• Any respiratory distress 1
• Comorbidities that compromise cardiopulmonary reserve or increase risk for severe disease 1

Monitoring Requirements

If a patient with respiratory disease has been vaping, they require:

• Immediate discontinuation of all vaping products 1
• Chest X-ray if experiencing chest pain, shortness of breath, or other respiratory symptoms 1
• Vital signs, pulse oximetry, and focused respiratory examination 1
• Low threshold for hospital admission given their high-risk status 1

Common Pitfalls to Avoid

Misconception About "Natural" Products

• Many incorrectly perceive herbal or nicotine-free vaping products as harmless, but this perception is not supported by evidence 8, 5.
• The absence of nicotine does not make mullein vaping safe—the respiratory risks stem from the vaping process itself, not solely the nicotine content 1, 2.

Dual Use Dangers

• Patients should never use both combustible cigarettes and vaping products simultaneously, as this increases rather than reduces harm 8, 5.
• If patients are attempting smoking cessation, proven behavioral counseling and FDA-approved pharmacotherapy should be recommended instead of any vaping product 5, 6.

Delayed Recognition of Symptoms

• EVALI can present with nonspecific symptoms (fever, cough, fatigue, nausea) that may be attributed to other causes 1.
• Median time to rehospitalization is only 4 days, and median time to death after discharge is 3 days, requiring aggressive early intervention 1.

Bottom Line for Clinical Practice

For any patient with pre-existing respiratory conditions, the answer is clear: avoid both mullein vaping and nicotine vaping entirely. The American Thoracic Society, European Respiratory Society, and CDC all emphasize that vaping products pose unacceptable risks, particularly for vulnerable populations with compromised lung function 1. There is no "safer" vaping option for these patients—complete abstinence from all inhaled vaporized products is the only medically sound recommendation 8, 5, 6.