Brownstone Institute
Kheriaty vs. University of California
From the Brownstone Institute
BY
Shortly after I published the Wall Street Journal piece arguing that university vaccine mandates were unethical, the University of California, my employer, promulgated its vaccine mandate. I decided then it was time to put a stake in the ground: I filed a lawsuit in federal court challenging the constitutionality of the university’s vaccine mandate on behalf of COVID-recovered individuals. It was already clear from many robust studies that natural immunity following infection was superior to vaccine-mediated immunity in terms of efficacy and duration of immunity.
At the time I was an unlikely candidate to challenge the prevailing vaccination policies. I was deeply embedded in the academic medical establishment, where I had spent my entire career. In my capacity as a psychiatric consultant on the medical wards and in the emergency department, I had suited up in PPE (personal protective equipment) to see hundreds of hospitalized COVID patients, witnessing the worst that this illness can do. Nobody needed to explain to me how bad this virus could be for some individuals, especially the elderly with co-occurring medical conditions who were at significant risk of bad outcomes when infected.
I contracted the virus in July 2020, and despite my efforts to self-isolate, passed it to my wife and five children. Living and breathing COVID for a year, I eagerly awaited a safe and effective vaccine for those that were still not immune to this virus. I happily served on the Orange County COVID-19 Vaccine Task Force, and I advocated in the Los Angeles Times that the elderly and sick be prioritized for vaccination, and that the poor, disabled, and underserved be given ready access to vaccines.
I had worked every day for over a year to develop and advance the university’s and state’s pandemic mitigation measures. But as the prevailing COVID policies unfolded, I became increasingly concerned, and eventually disillusioned. Our one-size-fits-all coercive mandates failed to take account of individualized risks and benefits, particularly age-stratified risks, which are central to the practice of good medicine. We ignored foundational principles of public health, like transparency and the health of the entire population. With little resistance we abandoned foundational ethical principles.
Among the most glaring failures of our response to COVID was the refusal to acknowledge the natural immunity of COVID-recovered patients in our mitigation strategies, herd-immunity estimates, and vaccine-rollout plans. The CDC estimated that by May 2021, more than 120 million Americans (36 percent) had been infected with COVID. Following the Delta-variant wave later that year, many epidemiologists estimated the number was close to half of all Americans. By the end of the Omicron wave in early 2022, that number was north of 70 percent. The good news — almost never mentioned — was that those with previous infection had more durable and longer-lasting immunity than the vaccinated. Yet the focus remained exclusively on vaccines.
As I argued in a coauthored article, medical exemptions for most vaccine mandates were too narrowly tailored, constraining physicians’ discretionary judgment and seriously compromising individualized patient care. Most mandates only allowed medical exemptions for conditions included on the CDC’s list of contraindications to the vaccines — a list that was never meant to be comprehensive. CDC recommendations should never have been taken as sound medical advice applicable to every patient.
Further exacerbating this problem, on August 17, 2021, all licensed physicians in California received a notification from the state medical board with the heading “Inappropriate Exemptions May Subject Physicians to Discipline.” Physicians were informed that any doctor granting an inappropriate mask exemption or other COVID-related exemptions “may be subjecting their license to disciplinary action.” In what was perhaps a deliberate omission, the “standard of care” criteria for vaccine exemptions was never defined by the medical board. In my eighteen years as a licensed physician, I had never previously received any such notice, nor had my colleagues.
The effect was chilling: since physicians naturally interpreted “other exemptions” to include vaccines, it became de facto impossible to find a doctor in California willing to write a medical exemption, even if the patient had a legitimate contraindication to the COVID vaccines. One of my patients was told by his rheumatologist he should not get the COVID vaccine, since he was at low risk from COVID and in this physician’s judgment his autoimmune condition elevated his risks of vaccine adverse effects.
This patient, who was subjected to a vaccine mandate at work, immediately asked this same physician for a medical exemption. The doctor replied, “I’m sorry, I cannot write you an exemption because I’m afraid I might lose my license.” I heard many stories of similar egregious violations of medical ethics under these repressive mandates and the enforcement regime that bolstered them.
As the vaccines rolled out in 2021, I spoke to many students, faculty, residents, staff, and patients who were aware of these basic immunological facts and were asking legitimate questions about vaccine mandates. Many correctly saw no medical or public health justification for subjecting themselves to the risks of the novel vaccines when they already had superior natural immunity. Others had moral concerns but did not qualify for a religious exemption, because religion was not central to their conscience-based objections.
They felt intimidated, disempowered, and vulnerable in the face of immense pressure to go along. Many physicians and nurses were afraid to speak up in the climate of coercion. Public health officials ignored inconvenient scientific findings, suppressed reasonable questions, and bullied into silence any skeptical physicians or scientists. Institutions promulgating mandates stigmatized and punished those who refused to comply. I had never seen anything like this in medicine.
Why did I file a lawsuit in federal court against my own employer? I had nothing to gain personally by this and a lot to lose professionally. I decided I could not stand by and watch the ethical disaster unfold around me without attempting to do something. In my position as Director of Medical Ethics at UCI, I had a duty to represent those whose voices were silenced and to insist upon the right of informed consent and informed refusal.
In the end, my decision to challenge these mandates came down to this question: How could I continue to call myself a medical ethicist if I failed to do what I was convinced was morally right under pressure? Projecting ahead to the required medical ethics course I taught to first and second-year medical students at the beginning of each year, I could not imagine lecturing on informed consent, moral courage, and our duty to protect patients from harm if I had failed to oppose these unjust and unscientific mandates. I simply would not have woken up each day with a clear conscience.
The university did not take kindly to my legal challenge, as you might imagine. Administrators allowed no grass to grow under their feet before responding to this dissident within the ranks. I had petitioned the court for a preliminary injunction to put the vaccine mandate on hold while the case was litigated in court. The judge declined this request, and the following day the university placed me on “investigatory leave” for alleged noncompliance with the vaccine mandate. Instead of waiting for the federal court to decide my case, the university immediately banned me from working on campus or working from home.
I was given no opportunity to contact my patients, students, residents, or colleagues and let them know I would suddenly disappear. An email from one of the deans, sent after I had left the office for the day, informed me that I could not return to campus the following day.
As I drove away from campus for the last time that day, I glanced at the sign on the corner near the hospital. The sign, which had been up for months, read in large block letters, HEROES WORK HERE.
Republished from the author’s Substack
Brownstone Institute
Bizarre Decisions about Nicotine Pouches Lead to the Wrong Products on Shelves
From the Brownstone Institute
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.
A Better Balance: Enforce Upstream, Widen the Legal Path
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.
Addictions
The War on Commonsense Nicotine Regulation
From the Brownstone Institute
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.
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