Connect with us
[the_ad id="89560"]

Brownstone Institute

Medicine in the Wilderness

Published

10 minute read

From the Brownstone Institute

BY Russ GonneringRUSS GONNERING  

I once was proud of my profession. I spent over 40 years as a clinician, educator, and researcher and for most of that time thought I was engaged in a noble calling. But all that has changed in the last 3 years. Medicine is lost in The Wilderness.

There were warning signals, to be sure. For many years I was heavily involved in medical associations on the local, state, and national levels. Gradually I became disillusioned when I saw that many of my colleagues who gravitated to this activity did not share my views. They enjoyed the politics of medicine. In fact, they enjoyed it too much. I lost interest. Perhaps in retrospect that was part of the problem. The policy of medicine gradually became the politics of medicine. And as is often the case, where there is politics there is also corruption.

Twenty years ago I was appointed as a technical advisor to a panel of the federal government. I was flown to Washington, housed in an upscale hotel and dined on fancy meals. I saw how intoxicating power can be. I began to somehow consider that I was special. The problem was I was expected to use my technical expertise to advise in a certain way. I realized, almost too late, what was going on. But I did realize it and was not reappointed to that position.

Looking back on it, this experience gave me a taste of how the events of the past three years came to be. I saw how money, power and flattery could cause physicians to shade their recommendations. It happened oh so gradually until one day, integrity was completely lost. The tragedy is that many times, those who lost it did not miss it.

I have come to realize that ethics and medicine have parted ways for many physicians, myself included. Things we once took for granted are gone…evaporated. We reached a point where, relating to COVID, attempts to treat disease were not just ignored but penalized. As a surgeon, I had operated under the obligation of giving Informed Consent to all my patients. I was expected to clearly explain the risks, benefits, and alternatives of my proposed course of action and allow the patient to make the decisions regarding their response to those recommendations. I could be sanctioned for failing in this obligation. However, in COVID, Informed Consent was criminalized…but only for that disease. Those who still felt an obligation to their patients were, and continue to be, vilified, slandered, fired from their position, and in some cases, prosecuted.

One would have thought that organized medicine, and academic medicine in particular, would have rallied to their defense, but that was not the case. They were the primary prosecutors. I shake my head when I think back to the days that I taught medical ethics to residents and medical students. One of the case studies involved discussing how accepting a lunch, or even a pen, from a drug company was unethical. Somehow, individuals who made life and death decisions were suspected of being bribed by a pen! And owning stock in a company and prescribing medications manufactured by that company were absolutely forbidden!

Now where are we? A good deal past the use of pens, for sure!

If a physician from even 10 years ago would look at the contents of most of our medical journals today, I am sure he or she would think they were reading fiction. These are the four articles that make up the Viewpoint section of the September 19, 2023 issue of the Journal of the American Medical Association.

In order to truly understand the departure from what was the norm a mere 10 years ago, this is a link to the contents of the Viewpoint section in the September 18, 2013 issue:

The difference in the tenor of the articles is striking, at least to me. In the current articles, the author’s primary focus seems to be finding ways to circumvent the rule of law. In 2013, the two articles that deal with a legislative focus explore how to comply with the rule of law. While some may claim that is a distinction without a difference, I would disagree. Something has changed! Change is inevitable, but is it always positive? Looking back on history, many nations have changed in response to internal and external pressure. Unfortunately, the majority of those changes have been negative.

Back in 2019, before the Great COVID disaster, Baffy and associates warned us of a change that was occurring in medical and scientific publishing. They observed the concentration of medical and scientific publishing in the hands of a few very large corporations which answered to stakeholders with conflicting interests:

Because the use of complex digital tools and rapidly growing electronic databases require advanced computing skills, Internet-based mega-companies such as Google (Mountainview, Calif), Amazon (Seattle, Wash), Facebook (Menlo Park, Calif), and Apple (Cupertino, Calif) may become interested in spearheading further transformation and outcompete current stakeholders in scholarly communication and develop more user-friendly tools. Such developments could potentially lead to a few large entities controlling the gateways to scientific knowledge, a sobering thought…

Scientific publishing has been a highly profitable industry, and there is little doubt that financial interests will continue to drive its transformation. However, the academic community has a fundamental stake in this process and should understand the trajectories of change to protect enduring values, embrace promising developments, and make scholarly communication increasingly inclusive and efficient.

It would seem the authors were amazingly prescient, as their world has come to pass. Medicine seems, at least to me, to have become the Willing Servant of an Unholy Trinity of Big Pharma, Big Tech and Big Politics. Medical publication and medical education have become more interested in ideology and propaganda than healing, more interested in class than the individual. It is the very antithesis of the concepts contained in the Hippocratic Oath. Although the proponents of the transformation may claim it is being done for a “greater good,” that excuse has been used before in medicine of some nations of the last century. When sanity returned, that excuse was repudiated.

Society now finds itself a passenger on a ship which has been taken over by ideologues. The ship is heading for the rocks. Lookouts stationed high above can see the disaster unfolding and urgently inform the captain of the ship. The captain solves the problem by throwing the lookouts overboard.

This is the dystopian world in which we now live.

Author

  • Russ Gonnering

    Russ S. Gonnering is Adjunct Professor of Ophthalmology, Medical College of Wisconsin.

Before Post

Todayville is a digital media and technology company. We profile unique stories and events in our community. Register and promote your community event for free.

Follow Author

Brownstone Institute

Bizarre Decisions about Nicotine Pouches Lead to the Wrong Products on Shelves

Published on

From the Brownstone Institute

  Roger Bate  

A walk through a dozen convenience stores in Montgomery County, Pennsylvania, says a lot about how US nicotine policy actually works. Only about one in eight nicotine-pouch products for sale is legal. The rest are unauthorized—but they’re not all the same. Some are brightly branded, with uncertain ingredients, not approved by any Western regulator, and clearly aimed at impulse buyers. Others—like Sweden’s NOAT—are the opposite: muted, well-made, adult-oriented, and already approved for sale in Europe.

Yet in the United States, NOAT has been told to stop selling. In September 2025, the Food and Drug Administration (FDA) issued the company a warning letter for offering nicotine pouches without marketing authorization. That might make sense if the products were dangerous, but they appear to be among the safest on the market: mild flavors, low nicotine levels, and recyclable paper packaging. In Europe, regulators consider them acceptable. In America, they’re banned. The decision looks, at best, strange—and possibly arbitrary.

What the Market Shows

My October 2025 audit was straightforward. I visited twelve stores and recorded every distinct pouch product visible for sale at the counter. If the item matched one of the twenty ZYN products that the FDA authorized in January, it was counted as legal. Everything else was counted as illegal.

Two of the stores told me they had recently received FDA letters and had already removed most illegal stock. The other ten stores were still dominated by unauthorized products—more than 93 percent of what was on display. Across all twelve locations, about 12 percent of products were legal ZYN, and about 88 percent were not.

The illegal share wasn’t uniform. Many of the unauthorized products were clearly high-nicotine imports with flashy names like Loop, Velo, and Zimo. These products may be fine, but some are probably high in contaminants, and a few often with very high nicotine levels. Others were subdued, plainly meant for adult users. NOAT was a good example of that second group: simple packaging, oat-based filler, restrained flavoring, and branding that makes no effort to look “cool.” It’s the kind of product any regulator serious about harm reduction would welcome.

Enforcement Works

To the FDA’s credit, enforcement does make a difference. The two stores that received official letters quickly pulled their illegal stock. That mirrors the agency’s broader efforts this year: new import alerts to detain unauthorized tobacco products at the border (see also Import Alert 98-06), and hundreds of warning letters to retailers, importers, and distributors.

But effective enforcement can’t solve a supply problem. The list of legal nicotine-pouch products is still extremely short—only a narrow range of ZYN items. Adults who want more variety, or stores that want to meet that demand, inevitably turn to gray-market suppliers. The more limited the legal catalog, the more the illegal market thrives.

Why the NOAT Decision Appears Bizarre

The FDA’s own actions make the situation hard to explain. In January 2025, it authorized twenty ZYN products after finding that they contained far fewer harmful chemicals than cigarettes and could help adult smokers switch. That was progress. But nine months later, the FDA has approved nothing else—while sending a warning letter to NOAT, arguably the least youth-oriented pouch line in the world.

The outcome is bad for legal sellers and public health. ZYN is legal; a handful of clearly risky, high-nicotine imports continue to circulate; and a mild, adult-market brand that meets European safety and labeling rules is banned. Officially, NOAT’s problem is procedural—it lacks a marketing order. But in practical terms, the FDA is punishing the very design choices it claims to value: simplicity, low appeal to minors, and clean ingredients.

This approach also ignores the differences in actual risk. Studies consistently show that nicotine pouches have far fewer toxins than cigarettes and far less variability than many vapes. The biggest pouch concerns are uneven nicotine levels and occasional traces of tobacco-specific nitrosamines, depending on manufacturing quality. The serious contamination issues—heavy metals and inconsistent dosage—belong mostly to disposable vapes, particularly the flood of unregulated imports from China. Treating all “unauthorized” products as equally bad blurs those distinctions and undermines proportional enforcement.

My small Montgomery County survey suggests a simple formula for improvement.

First, keep enforcement targeted and focused on suppliers, not just clerks. Warning letters clearly change behavior at the store level, but the biggest impact will come from auditing distributors and importers, and stopping bad shipments before they reach retail shelves.

Second, make compliance easy. A single-page list of authorized nicotine-pouch products—currently the twenty approved ZYN items—should be posted in every store and attached to distributor invoices. Point-of-sale systems can block barcodes for anything not on the list, and retailers could affirm, once a year, that they stock only approved items.

Third, widen the legal lane. The FDA launched a pilot program in September 2025 to speed review of new pouch applications. That program should spell out exactly what evidence is needed—chemical data, toxicology, nicotine release rates, and behavioral studies—and make timely decisions. If products like NOAT meet those standards, they should be authorized quickly. Legal competition among adult-oriented brands will crowd out the sketchy imports far faster than enforcement alone.

The Bottom Line

Enforcement matters, and the data show it works—where it happens. But the legal market is too narrow to protect consumers or encourage innovation. The current regime leaves a few ZYN products as lonely legal islands in a sea of gray-market pouches that range from sensible to reckless.

The FDA’s treatment of NOAT stands out as a case study in inconsistency: a quiet, adult-focused brand approved in Europe yet effectively banned in the US, while flashier and riskier options continue to slip through. That’s not a public-health victory; it’s a missed opportunity.

If the goal is to help adult smokers move to lower-risk products while keeping youth use low, the path forward is clear: enforce smartly, make compliance easy, and give good products a fair shot. Right now, we’re doing the first part well—but failing at the second and third. It’s time to fix that.

Author

Roger Bate

Roger Bate is a Brownstone Fellow, Senior Fellow at the International Center for Law and Economics (Jan 2023-present), Board member of Africa Fighting Malaria (September 2000-present), and Fellow at the Institute of Economic Affairs (January 2000-present).

Continue Reading

Addictions

The War on Commonsense Nicotine Regulation

Published on

From the Brownstone Institute

Roger Bate  Roger Bate 

Cigarettes kill nearly half a million Americans each year. Everyone knows it, including the Food and Drug Administration. Yet while the most lethal nicotine product remains on sale in every gas station, the FDA continues to block or delay far safer alternatives.

Nicotine pouches—small, smokeless packets tucked under the lip—deliver nicotine without burning tobacco. They eliminate the tar, carbon monoxide, and carcinogens that make cigarettes so deadly. The logic of harm reduction couldn’t be clearer: if smokers can get nicotine without smoke, millions of lives could be saved.

Sweden has already proven the point. Through widespread use of snus and nicotine pouches, the country has cut daily smoking to about 5 percent, the lowest rate in Europe. Lung-cancer deaths are less than half the continental average. This “Swedish Experience” shows that when adults are given safer options, they switch voluntarily—no prohibition required.

In the United States, however, the FDA’s tobacco division has turned this logic on its head. Since Congress gave it sweeping authority in 2009, the agency has demanded that every new product undergo a Premarket Tobacco Product Application, or PMTA, proving it is “appropriate for the protection of public health.” That sounds reasonable until you see how the process works.

Manufacturers must spend millions on speculative modeling about how their products might affect every segment of society—smokers, nonsmokers, youth, and future generations—before they can even reach the market. Unsurprisingly, almost all PMTAs have been denied or shelved. Reduced-risk products sit in limbo while Marlboros and Newports remain untouched.

Only this January did the agency relent slightly, authorizing 20 ZYN nicotine-pouch products made by Swedish Match, now owned by Philip Morris. The FDA admitted the obvious: “The data show that these specific products are appropriate for the protection of public health.” The toxic-chemical levels were far lower than in cigarettes, and adult smokers were more likely to switch than teens were to start.

The decision should have been a turning point. Instead, it exposed the double standard. Other pouch makers—especially smaller firms from Sweden and the US, such as NOAT—remain locked out of the legal market even when their products meet the same technical standards.

The FDA’s inaction has created a black market dominated by unregulated imports, many from China. According to my own research, roughly 85 percent of pouches now sold in convenience stores are technically illegal.

The agency claims that this heavy-handed approach protects kids. But youth pouch use in the US remains very low—about 1.5 percent of high-school students according to the latest National Youth Tobacco Survey—while nearly 30 million American adults still smoke. Denying safer products to millions of addicted adults because a tiny fraction of teens might experiment is the opposite of public-health logic.

There’s a better path. The FDA should base its decisions on science, not fear. If a product dramatically reduces exposure to harmful chemicals, meets strict packaging and marketing standards, and enforces Tobacco 21 age verification, it should be allowed on the market. Population-level effects can be monitored afterward through real-world data on switching and youth use. That’s how drug and vaccine regulation already works.

Sweden’s evidence shows the results of a pragmatic approach: a near-smoke-free society achieved through consumer choice, not coercion. The FDA’s own approval of ZYN proves that such products can meet its legal standard for protecting public health. The next step is consistency—apply the same rules to everyone.

Combustion, not nicotine, is the killer. Until the FDA acts on that simple truth, it will keep protecting the cigarette industry it was supposed to regulate.

Author

Roger Bate

Roger Bate is a Brownstone Fellow, Senior Fellow at the International Center for Law and Economics (Jan 2023-present), Board member of Africa Fighting Malaria (September 2000-present), and Fellow at the Institute of Economic Affairs (January 2000-present).

Continue Reading

Trending

X