The Association Between Vape Shop Density and E-cigarette, or Vaping, Product-Use Associated Lung Injury in Adolescents

Abstract

Rationale: In 2019, the clinical manifestations of an outbreak of e-cigarette, or vaping, product useassociated lung injury (EVALI) in the United States was described and linked to vitamin E acetate, an additive used to dilute tetrahydrocanninol (THC). It is unknown whether access to vape shops influence adolescent e-cigarette literacy and increase the risk for EVALI. This study aims to elucidate associations between adolescent EVALI cases and neighborhood vape shop density. Methods: ZIP codes of EVALI cases in adolescents hospitalized at Children's Health Medical Center Dallas from December 2018 - June 2021 were retrospectively identified using the Centers for Disease Control and Prevention case definition. ZIP codes without EVALI cases were identified through the American Community Survey 2019 data and matched to the EVALI ZIP codes 2:1 using population size and age distribution. Vape shop locations were obtained by cross-referencing search results from Google Maps and Yelp. Vape shop density was mapped per ZIP code using ESRI ArcMap geospatial processing software. Hotspots were identified using graduated symbols. Data distribution of vape shop density was assessed with the Shapiro Wilk test for normality. Differences in vape shop density by ZIP code group (EVALI/no EVALI) was assessed with the Wilcoxon Rank Sum test. Results: The mean age of adolescents with EVALI (n=41) was 16.3 years (SD=1.1) (66% male;61% Hispanic, 39% non-Hispanic white). There were 34 corresponding ZIP codes, with five containing two EVALI cases and one containing three cases. 64% of our cohort were identified after the World Health Organization's declaration that COVID-19 was a pandemic, 66% obtained their vaping products from informal sources, 95% smoked primarily THC containing products, and 15% smoked “Dank” vapes. No significant difference in vape shop density was found between the 130 ZIP codes without EVALI cases (0.30 shops/mi2, SD=0.48) and the 34 ZIP codes with at least one EVALI case (0.24 shops/mi2, SD=0.24, p=0.98). Conclusions: Findings here show no association between ZIP code-level vape shop density and EVALI cases, suggesting that interventions should not be focused on regulating vape shops alone. This lack of association may be due to decreased vape shop accessibility during the COVID-19 pandemic and/or the origin of ecigarettes mainly from informal sources. Further research should investigate the association between other neighborhood characteristics and EVALI with the goal of implementing targeted prevention programs in at-risk neighborhoods to mitigate the impact of this new epidemic.