years, receptivity to e-cigarette marketing is associated with susceptibility to traditional cigarette smoking. prevention of youth exposure to e-cigarette advertising might, therefore, be important for prevention of youth use of all tobacco products, according to a 2018 morbidity and mortality weekly report. the us surgeon general has concluded that e-cigarette marketing employs strategies similar to traditional cigarette advertising tactics that have been proven to appeal to youths, such as themes of romance, freedom, and rebellion; celebrity endorsements; and health claims. exposure to e-cigarette advertising might reduce youths' perception of harm associated with e-cigarettes and increase their beliefs that e-cigarettes can be used where smoking is prohibited. product design features might also influence use. for example, juul, the top-selling us e-cigarette brand, is an e-cigarette shaped like a usb flash drive that has a high nicotine concentration. according to news reports and social media posts, students are using juul in school classrooms and bathrooms. in addition, e-cigarettes are marketed and promoted using strategies that are not legally permissible for traditional cigarettes, including television, sports, and music event sponsorships, in-store self-service displays, and advertisements placed outside of brick-and-mortar businesses at children's eye level. exposure to e-cigarette advertisements increased among us middle and high school students during 2014–2016. as part of comprehensive youth tobacco prevention efforts, approaches to reduce youth access to e-cigarettes and exposure to e-cigarette advertising could include regulation of youth-oriented marketing, restrictions on youth access to tobacco products in retail settings, and high-impact youth-focused tobacco education campaigns. these approaches, coupled with comprehensive state tobacco control programs, have the potential to prevent and reduce youth use of all tobacco products, including e-cigarettes, according to a 2018 morbidity and mortality weekly report. in 2019, a review in the current atherosclerosis reports journal stated: the tobacco and e-cigarette companies continue to use sophisticated advertising to promote their products, as they have historically. they place ads on social media, sponsor music festivals and other events, host interactive photo booths, and distribute free samples. they also make and promote kid-friendly flavors like cotton candy and gummi bear. youth use is a particular concern. a systematic review and meta analysis found e-cigarette use was clearly associated with current smoking and a "strong risk factor" for future smoking among youth. graphic from the 2019 us surgeon general's report entitled marketing to youth and young adults marketing to youth investigations juul e-cigarette with pods. the device looks like a usb flash drive. in april 2018, the us fda began investigating juul's marketing approaches. they were under investigation by the us fda to determine if they were marketing juul to youth. the us fda made an unannounced inspection of juul headquarters in late september 2018 to gather information on their marketing methods, among other things. the us fda collected over a thousand pages of information on the company. "the inspection followed the agency's request for information that we issued to juul labs in april for documents that would help us to better understand the reportedly high rates of youth use and the youth appeal of juul products, including documents related to marketing and product design," the fda stated. the massachusetts attorney general maura healey in july 2018 investigated juul and other online e-cigarette sellers for purportedly marketing to minors. the attorney general's office sent letters to two online retailers in july 2018, telling them to desist offering for sale juul and other products in the state without setting up a system to verify the age of customers as mandated by state law. the attorney mike feuer of los angeles, ca said on october 31, 2018, that vapeco distribution, its other company newhere inc., and kandypens inc. were marketing e-cigarette products to minors. the city of los angeles stated that the three companies are offering for sale e-cigarette products online without providing an adequate age-verification system and are targeting minors in their marketing efforts, among other things. in 2018, the attorney's office of los angeles had been trying to get an injunction to put an end to those practices. there are e-cigarettes that are designed to look similar to everyday objects like usb flash drives in an effort to conceal their use from teachers and parents. for example, juul looks like a usb flash drive that could contain music or photos. teachers can easily be misled into believing the device is a usb flash drive. teachers believe the device's compact design and sugary flavors are targeted at minors. "the prevalence of juuls has also been intensified due to marketing of juuls to high schoolers. juuls look like flash drives because kids must hide them. no adult needs to have a vape that looks like a flash drive; they don't need to hide that," sean christensen, a high schooler from towson, maryland, stated in 2018. the us fda announced on september 12, 2018, that a series of critical and historic enforcement actions related to the sale and marketing of e-cigarettes to youth. in the largest coordinated enforcement effort in the fda's history, the agency issued more than 1,300 warning letters and civil money penalty complaints (fines) to retailers who illegally sold juul and other e-cigarette products to minors during a nationwide, undercover blitz of brick-and-mortar and online stores this summer. as a result of these violations of the law – and other indications that e-cigarette use among youth has hit epidemic proportions – fda commissioner scott gottlieb, signaled that the agency intends to take new and significant steps to address this challenge in a speech at the agency's headquarters. juul's marketing approaches have come under scrutiny for its advertisements reportedly aimed at appealing to youth. in november 2018, juul labs announced they would hold off on selling the majority of its flavored e-cigarette pods in retail stores and would cease promoting is products on social media. they also stated that they would resume sales of the flavored products at retail stores that put into practice an age-verification system. reestablishing the sales of the flavored products to retailers was not specified during the juul announcement. tobacco, mint, and menthol pods will still be sold to retailers. in august 2019, juul labs announced new protocols in the us to curb e-cigarette use among minors. the company is setting up an age-verification point-of-sale system, called the retail access control standards (racs) program, for retailers. retailers have stated they support the system. health advocates are concerned that juul could be offsetting its restrictions in the us by switching its attention to countries that are less affluent. for example, juul's approach in the philippines is different than in caparison with us. in the philippines juul sells fruit and other non-tobacco flavors, while juul has stopped allowing these flavors to be sold by us retailers. a juul retailer salesperson in manila purportedly said to a teenager that juuling is safer than smoking. on october 17, 2019, juul announced that it would suspend the sale of its mango, creme, fruit, and cucumber flavors in the us. mango, creme, fruit, and cucumber flavors are no longer being sold at its online store. other countries are continuing to sell juul's flavored pods. before juul's instagram account called juul vapor was shut down in november 2018, an investigation "found that over 90% of posts were related to lifestyle appeal, displaying pictures and videos meant to evoke feelings of relaxation, freedom, and sex appeal in the context of the juul product and flavor images." juul's official instagram account has closed, but others such as the #doit4juul hashtag stayed open. the fan account #doit4juul, with 110,000 followers in 2018, has different kinds of images than juul's official instagram account had. #doit4juul had an image of a bodybuilder using the juul device who was wearing a shirt that read "real men eat ass". it also had an image of a shirtless college student with a juul between her lips. several new accounts have launched in 2018 on the site, such as doingit4juul that depicts youth using the device. videos of young people using their juul device in classrooms or locker rooms have appeared on social media. "we're committed to the comprehensive approach to address addiction to nicotine that we announced last year. but at the same time, we see clear signs that youth use of electronic cigarettes has reached an epidemic proportion, and we must adjust certain aspects of our comprehensive strategy to stem this clear and present danger. this starts with the actions we're taking today to crack down on retail sales of e-cigarettes to minors. we will also revisit our compliance policy that extended the dates for manufacturers of certain flavored e-cigarettes to submit applications for premarket authorization. i believe certain flavors are one of the principal drivers of the youth appeal of these products. while we remain committed to advancing policies that promote the potential of e-cigarettes to help adult smokers move away from combustible cigarettes, that work can't come at the expense of kids. we cannot allow a whole new generation to become addicted to nicotine. in the coming weeks, we'll take additional action under our youth tobacco prevention plan to immediately address the youth access to, and the appeal of, these products," said fda commissioner gottlieb, on september 12, 2018. "today, we asked five e-cigarette manufacturers to put forward plans to immediately and substantially reverse these trends, or face a potential decision by the fda to reconsider extending the compliance dates for submission of premarket applications. our comprehensive plan on nicotine and tobacco regulation remains intact and we remain committed to its goals to reduce tobacco-related disease and death, including our efforts to reduce the nicotine in combustible products to render cigarettes minimally or non-addictive. we're also fully committed to the concept that products that deliver nicotine exist on a continuum of risk, with combustible products representing the highest risk, and electronic nicotine delivery systems perhaps presenting an alternative for adult smokers who still seek access to satisfying levels of nicotine, but without all of the harmful effects that come from combustion. but in enabling a path for e-cigarettes to offer a potentially lower-risk alternative for adult smokers, we won't allow the current trends in youth access and use to continue, even if it means putting limits in place that reduce adult uptake of these products," the us fda stated on september 12, 2018. on september 12, 2018, the us fda issued 12 warning letters to online retailers that were selling misleadingly labeled and/or advertised e-liquids resembling kid-friendly food products such as candy and cookies. on october 12, 2018, the us fda sent letters to 21 e-cigarette companies, including the manufacturers and importers of vuse alto, myblu, myle, rubi and stig, seeking information about whether more than 40 products – including some flavored e-cigarette products – are being illegally marketed and outside the agency's current compliance policy. these new actions build on those taken by the fda in recent weeks as part of its youth tobacco prevention plan to address the epidemic of youth e-cigarette use, including cracking down on the sale and marketing of e-cigarettes to kids and educating youth about the dangers of using these products. "companies are on notice – the fda will not allow the proliferation of e-cigarettes or other tobacco products potentially being marketed illegally and outside of the agency's compliance policy, and we will take swift action when companies are skirting the law. given the explosive growth of e-cigarette use by kids, we're committed to taking whatever measures are appropriate to stem these troubling use trends. we're going to address issues related to the access kids have to e-cigarettes, as well as the youth appeal of these products. if products are being unlawfully marketed and outside the fda's compliance policy, we'll act to remove them. this includes revisiting our compliance policy that has resulted in certain e-cigarettes, including flavored e-cigarettes, remaining on the market until 2022 while their manufacturers submit applications for premarket authorization. further, many of these products pose particular concerns given their use of flavors. we know flavors are one of the principal drivers of the youth appeal of e-cigarettes and we're looking carefully at this," said fda commissioner scott gottlieb, on october 12, 2018. "the fda remains committed to the potential opportunity for e-cigarettes to help adult smokers transition away from combustible cigarettes. but we cannot allow that