A survey study of urban retailers selling alkyl nitrites ("poppers") in the New York City area which led to public health interventions.

Introduction: Alkyl nitrites ("poppers") are used recreationally for sexual enhancement, muscle relaxation, and euphoria. However, they can be toxic and cause adverse reactions such as methemoglobinemia. While inhalation is the typical route of usage, the New York City Poison Center has noted an increase in calls related to ingestion. Given the uncertainty of usage instructions at the point of sale, our study aimed to assess instructions provided to consumers about alkyl nitrite use and to evaluate the proximity and co-sale of alkyl nitrites with similarly appearing energy drink shots.

Methods: We conducted a cross-sectional convenience sample survey of smoke shops, cannabis dispensaries, and exotic shops within the catchment area of an urban poison center. Plain clothes "investigators" (i.e., the researchers) visited these retailers and followed a predetermined protocol and script to request information regarding the availability and usage of alkyl nitrites. Additionally, the researchers attempted to visually assess the proximity of alkyl nitrites to similarly appearing energy drink shots during their visit.

Results: Ninety-eight stores were visited in the New York City area, and eighty-six met the inclusion criteria of selling alkyl nitrites. After being questioned, forty-one (48%) retailers advised inhalation. Thirty-eight (44%) vendors were unsure how to use alkyl nitrites or refused to answer. Seven (8%) stores recommended ingestion. Furthermore, fifty-one (59%) vendors also sold 5-Hour Energy drinks and alkyl nitrites were located near these energy drink shots in twenty (39%) of these fifty-one stores.

Discussion: Many commercial alkyl nitrite retailers in our survey area lack knowledge or provide potentially inaccurate information regarding the use of alkyl nitrites. Additionally, alkyl nitrites are often sold alongside commercial energy drinks, potentially increasing the risk of incidental ingestion.

Conclusions: Further research is necessary to determine the impact of these patterns of sale and potential misinformation. Discussing preliminary results of our survey with the New York City Department of Health led to the rapid creation of an informational poster and local outreach. Clinicians should report cases of alkyl nitrite use to their regional poison center to allow for more targeted and timely public health intervention.