Brownstone Institute
Fluoride in the Water
From the Brownstone Institute
By
Politico reports that RFK, Jr. plans to ban fluoridation, and the work is already underway. Multiple news outlets repeated this story, yet none of them checked the evidence.
According to the CDC, adding fluoridation to water supplies was among the 20th century’s top ten public health achievements.
“a cornerstone strategy for prevention of cavities in the US It is a practical, cost-effective, and equitable way for communities to improve their residents’ oral health regardless of age, education, or income.”
The CDC states that fluoridated water keeps teeth strong and reduces cavities by about 25% in children and adults.
To validate this statement, the CDC refers to two studies. The first, is a meta-analysis of 20 studies. Eleven studies examined the effectiveness of self- or clinically applied fluoride, and of the nine that examined the effectiveness of water fluoridation none were RCTs, and all were cross-sectional studies. Also, the review, which wasn’t systematic, included adults and no children. The conclusion was limited to suggesting fluoride effectively prevents caries in adults of all ages.
The second study was a Cochrane review. Notably, most studies (71%) were conducted before 1975, when fluoride toothpaste was widely introduced.
The review concludes that little contemporary evidence evaluates the effectiveness of water fluoridation in preventing caries. The observational nature of the studies, the high risk of bias, and the lack of generalisability to current lifestyles limit confidence in the size of the effect estimates.
The review goes on to say that insufficient information exists to determine whether initiating a water fluoridation program changes levels of tooth decay across socioeconomic status. No studies that met the review’s inclusion criteria investigated the effectiveness of water fluoridation in preventing tooth decay in adults.
RFK, Jr. says he would advise the water districts using fluoridation that a lot of science says safety studies still need to be done. RFK, Jr. considers fluoride an industrial waste. He also thinks a federal court ruling could speed up the end of fluoridation in the US.

A judge ordered the US Environmental Protection Agency (EPA) to undertake a risk assessment. Judge Edward Chen found fluoridation could cause developmental damage and lower IQ in children at the levels found in drinking water.
Following this judgment, four water systems, including Salt Lake City’s provider, have stopped or suspended fluoridation due to the ruling.
At the TTE office, we searched for updated evidence published in the last decade, including 32 reviews. A word of caution: the overworked staff at the TTE office is currently unable to assess the evidence fully.
Dental Caries (tooth decay)
A 2021 review of ten studies on Brazilian populations reported that water fluoridation effectively prevents dental caries in children younger than 13 years, even with the widespread use of fluoridated toothpaste. A further review of fluoride for under-fives reports the evidence supporting oral fluoride supplementation for caries prevention is limited and inconsistent.
The WHO reports fluoride intake has both beneficial effects – in reducing the incidence of dental caries – and negative effects – in causing tooth enamel and skeletal fluorosis following prolonged high exposure.
Potential Harms
Reviews include an assessment of dental fluorosis, which affects individuals of all ages, with the highest prevalence below age 11. A further review reported that in 6-18-year-olds, at a water fluoride level of less than 0.7 parts per million, dental fluorosis occurred in 13% (95% CI: 7.5-18%) of the children. Above two parts per million dental fluorosis prevalence rose to 98% (95% CI: 96‒100%). In some regions, the amount of fluoride in the water represents a public health problem as it exceeds national and international regulation levels.
Reviews also assessed an association with hypothyroidism and children’s intelligence. Regarding neurological disorders, the evidence was inconclusive, and the authors call for epidemiological studies to provide further evidence regarding the possible association. A call for evidence that is repeated for establishing whether there is an association with Hip Fracture Risk.
Reviews have also assessed the potential correlation with increased blood pressure, association with chronic kidney disease, and risk of fluoride contamination in groundwater and its impact on the safety and productivity of food and feed crops.
The Impact of Stopping Fluoride
A systematic review, including six cross-sectional design studies, indicated that fluorosis significantly decreased following either a reduction in fluoride concentration or the cessation of adding fluoride to the water supply.
A systematic review of 15 studies identified methodological considerations for designing community water fluoridation cessation studies. These studies would permit an assessment of the effects of cessation on dental caries and the impact on reducing harm.
So, Where Does This Leave RFK, Jr.?
Beware of the swift condemnation of anyone who asks questions. Experts will espouse that fluoride is well-tested, it definitively or significantly decreases caries, and it has no association with any harm—all without reference to the evidence. Furthermore, the argument is lost when an individual who puts forward questions about healthcare exposures is referred to as a denialist.
RFK, Jr. rightly asks questions about an intervention based on evidence going back to the 1930s. In the meantime, there have been growing concerns about harm and little contemporary evidence evaluating the effectiveness of water fluoridation in preventing caries. So, stopping fluoride in the context of epidemiological evaluations isn’t far off the mark.
This post was written by two old geezers who regularly clean their teeth, and remain overworked and apolitical.
Republished from the author’s Substack
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.
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.
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