63. Botox

Summary

Podcast Summary: The Economics of Everyday Things – Episode 63 “Botox”

Host: Zachary Crockett
Date: August 6, 2026

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Episode Overview

In this episode, journalist Zachary Crockett investigates the hidden economic, cultural, and historical dimensions of Botox. Once a deadly toxin found in spoiled sausage, Botox has become a multibillion-dollar business in cosmetic and therapeutic markets. Crockett traces its unlikely journey from a deadly substance to one of the world’s most popular minimally invasive procedures, revealing the science, marketing strategies, industry economics, social dynamics, and psychological factors that have made it a cultural phenomenon.

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Key Discussion Points and Insights

1. From Deadly Toxin to Miracle Drug

• Botox is derived from botulinum toxin, considered one of the most lethal substances on Earth (“100 billion times more toxic than cyanide” [03:55]).
• Initially discovered in Germany (1700s) as the cause of “sausage poisoning,” it killed via consumption of poorly prepared meats.
• After WWII, researchers began exploring its potential medical uses.

2. Medical Breakthroughs and the First Uses

• In the late 1970s, Dr. Alan Scott pioneered using highly purified, non-lethal botulinum toxin to treat strabismus (misaligned eyeballs).
  Notable quote:

  “That was the first entry into it being used clinically to make people better.” – Dr. Steven Williams [04:46]

• The resulting drug, Oculinum, medically paralyzed overactive eye muscles.
• Dr. Jean Carruthers, an ophthalmology professor, recounts the emotional impact of these early treatments:

  “I remember one patient who came in, led by his wife, by the hand. He couldn't open his eyes. And three days later, he sent me a picture of himself driving his red convertible.” – Dr. Jean Carruthers [05:16]

3. Accidental Discovery of Cosmetic Use

• Dr. Carruthers discovers that injections in the forehead, initially for spasms, reduce frown lines and create a “beautiful untroubled expression” [06:02].
• The first test subject for cosmetic use was the office receptionist, with striking results.

4. Commercialization and Early Marketing Challenges

• In 1991, Allergan acquired Oculinum and soon rebranded it as “Botox.”
• Decade-long journey to FDA approval for cosmetic use (early 2000s).
• Early sales were slow due to public skepticism—both fear of the toxin and stigma over “frozen faces.”
• Sociologist Dana Berkowitz explains:

  “They really wanted to get around that stigma… If you just use a little bit of Botox, you can still express yourself. It was couched in this post-feminist narrative of, you know, doing it for you.” – Dana Berkowitz [07:32]

5. Marketing Success and Industry Growth

• Allergan’s ad campaigns positioned Botox as empowering—“freedom of expression” [08:02].
• Results: Botox sales grew tenfold from 2000–2015; worldwide revenues now exceed $5.7 billion (2023) [08:17].
• Despite competition, Botox dominates ~70% of its market.

  “You can get Botox treatments from a credentialed doctor… but you can also get them at medical spas and even dentists’ offices.” – Zachary Crockett [02:21]

6. The Changing Demographics and Normalization

• Cultural norms have shifted: Millennials (and even Gen Z) often seek Botox as preventative care, unlike boomers who treat wrinkles after they appear.
• Dr. Carruthers:

  “Boomers treat things once they've happened. Millennials are into prevention and… thought, I don't want to go there quite as fast.” – Dr. Jean Carruthers [02:31]

• User story:

  “My life is still crazy. It's just as full as it was before, just with less lines.” – Tanya, Botox user [08:41]

7. How Botox Works and What It Doesn't Do

• Two main causes of wrinkles: loss of collagen (skin sags) and repeated facial movement.
• Botox only works on “dynamic” wrinkles (from movement), not those from collagen loss:

  “Botox is terrible for [nasolabial folds and marionette lines] because they're not caused by a lot of muscle activation.” – Dr. Steven Williams [11:56]

• For static wrinkles, fillers are recommended.

8. The Economics: Pricing, Accessibility, and Regulation

• Physicians buy a vial of cosmetic Botox (100 units) for $350–$700; each vial covers ~12 treatments.
• Usual markup is “about double” the wholesale price.

  “The treatment cost itself is usually about double what the cost of Botox is to us.” – Dr. Steven Williams [13:16]

• No federal regulations on who can inject Botox; estheticians and dentists administer in many states.
• Proliferation of med spas leads to price wars, industry consolidation by private equity, and a spike in fake/counterfeit Botox for sale.

  “There has been a little bit of a race to the bottom… we'll do $4 a unit or $5 a unit.” – Dr. Steven Williams [14:16]

9. Challenges: Counterfeit Botox and Risks

• Over 2,000 cases of counterfeit Botox sold by professionals reported in the last decade.
• Risks range from ineffective treatment to serious health consequences if improperly dosed or administered by unqualified staff.

10. The Subscription Model & Recurring Revenue

• Botox’s effects wear off after 3–4 months, ensuring recurring clientele—unique among cosmetic procedures.
• Dr. Williams:

  “Botox allows a continual relationship with patients… We have patients using Botox for almost 20 years now.” [15:50]

• Cost per visit: ~$500 vs. ~$10,000+ for plastic surgery (e.g., facelift).

11. The Social Pressure, Social Media & the Ethics of Beauty

• Increasing numbers of younger patients (even late teens) due to social media influencers and targeted marketing:

  “Every single one of them said that social media was the culprit. You used to get beautiful in private, and now… in public for the world to see.” – Dana Berkowitz [16:42]

• Economic incentives for public figures to preserve their appearance (“my face is my business card”).
• Berkowitz expresses personal ambivalence:

  “Does Botox work? Yes… Is this still problematic? Absolutely. Every single time I use Botox, I feel like I am individually failing at feminist ethics. It transforms our perception of what is normal, of what is beautiful, of what an aging face should and does look like.” [18:05]

• Dr. Williams acknowledges societal beauty bias and its pressures:

  “Society puts enormous pressure on people to look a certain way…People really like the things that Botox is able to do for them.” [18:37]

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Notable Quotes & Memorable Moments

• Botox’s Deadly Origins:
  “It was deemed to be around 100 billion times more toxic than cyanide.” – Narrator [03:55]

• Transformation for Patients:
  “He sent me a picture of himself driving his red convertible.” – Dr. Jean Carruthers [05:16]

• First Cosmetic Experience:
  “She had really impressive frown lines… We treated her and you could see this amazing difference.” – Dr. Jean Carruthers [06:42]

• Marketing Ethos:
  “Freedom of expression. That’s what it’s all about.” – Allergan ad copy (quoted by Crockett) [08:02]

• Market Domination:
  “Botox is still the undisputed king of the industry, accounting for around 70% of the market share in its category.” – Narrator [08:30]

• Recurring Business Model:
  “We have patients using Botox for almost 20 years now.” – Dr. Steven Williams [15:50]

• Feminist Dilemma:
  “Every single time I use Botox, I feel like I am individually failing at feminist ethics.” – Dana Berkowitz [18:05]

• Aging, Society, and Self-Perception:
  “Society puts enormous pressure on people to look a certain way… but people really like the things that Botox is able to do for them.” – Dr. Steven Williams [18:37]

• Botox Legacy:
  “I want to tell you right now, I haven’t frowned since 1987.” – Dr. Jean Carruthers [19:33]

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Timestamps for Important Segments

• Botox’s Origins and Lethality: 03:13–04:26
• Medical Breakthrough (Dr. Scott and Dr. Carruthers): 04:41–06:52
• Early Marketing & Overcoming Stigma: 07:20–08:17
• Explosive Industry Growth: 08:02–08:55
• How Botox Works (Science): 11:26–12:57
• Pricing, Market, and Regulation Issues: 13:02–14:55
• Recurring Revenue Model: 15:44–16:17
• Demographic Shift & Social Media Influence: 16:20–17:46
• Psychological Dilemmas and Societal Pressures: 17:46–19:14
• Parting Words (Carruthers): 19:33

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Conclusion

This episode unveils how Botox evolved from a feared poison to a symbol of aesthetic empowerment. Through interviews with medical pioneers, social scientists, and consumers, Zachary Crockett explores the economic mechanics and deep social shifts driving Botox’s rise. The drug’s history is a mirror for modern anxieties around aging, beauty, status, and self-image, making the economics of Botox about much more than skin deep.

Transcript

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[Zachary Crockett]

As a plastic surgeon in Northern California, Dr. Steven Williams performs a lot of operations.

[Dr. Steven Williams]

We tackle the full spectrum from head to toe, facelifts, blepharoplasties, liposuction, tummy tucks and breast augmentations.

[Zachary Crockett]

But one of his most in demand

[Narrator/Reporter]

treatments happens outside of the operating room.

[Zachary Crockett]

Every month, around 150 patients each pay hundreds of dollars to get one of

[Narrator/Reporter]

the most toxic substances on earth injected into their faces.

[Dr. Steven Williams]

Markets go up and down, the economy is good or bad, but Botox is one of those things that people will really, really try not to cut back on. Twenty years ago, people were very quiet about it, like I don't want anyone to know. But now it's part of what people see as self care.

[Narrator/Reporter]

Botox is often touted as a cosmetic miracle drug.

[Zachary Crockett]

A few injections can temporarily reduce wrinkles

[Narrator/Reporter]

and stave off signs of aging.

[Zachary Crockett]

Last year there were more than 9

[Narrator/Reporter]

million procedures involving Botox or competing injectable brands in the US Alone.

[Zachary Crockett]

You can get Botox treatments from a

[Narrator/Reporter]

credentialed doctor like Stephen Williams, who happens to be the president of the American Society of Plastic Surgeons.

[Zachary Crockett]

But you can also get them at medical spas and even dentists offices. And people are seeking them out much

[Narrator/Reporter]

earlier in life than they used to.

[Dr. Jean Carruthers]

I think we're seeing a generational shift in the patients. Boomers treat things once they've happened. Millennials are into prevention and they've taken a look at their boomer Parents and thought, I don't want to go there quite as fast. And so they've done. It's actually got a slang word, baby.

[Zachary Crockett]

Botox for the Freakonomics radio network. This is the economics of everyday things.

[Narrator/Reporter]

I'm Zachary Crockett.

[Zachary Crockett]

Today, Botox, before Botox was a lucrative business, it was a deadly toxin found in sausages.

[Dr. Steven Williams]

Like all crazy things, the story starts back in the 1700s.

[Zachary Crockett]

Again, that's Dr. Stephen Williams.

[Dr. Steven Williams]

In Germany, there's this phenomenon called sausage poisoning. People would consume uncured meats, and every once in a while, people would die. As time went on, people began to study it a little bit. And the first thing they did is they classified the symptoms. And they noticed that people kind of had flat faces, in effect, and sometimes would have a little bit less ability to move.

[Narrator/Reporter]

Researchers eventually isolated the toxin in these meats and gave it a name. Botulinum. Derived from the Latin word for sausage,

[Zachary Crockett]

it was deemed to be around 100

[Narrator/Reporter]

billion times more toxic than cyanide.

[Zachary Crockett]

So deadly, in fact, that it was

[Narrator/Reporter]

considered for use as a bioweapon.

[Dr. Steven Williams]

In a pure form. Botulinum toxin is incredibly, incredibly deadly. And so, of course, the military said, this is great. We have this thing that's really potentially deadly. And, you know, there was all this really nefarious stuff that was planned to do with it. There were even plans to maybe assassinate Castro by putting it in his cigar.

[Narrator/Reporter]

None of those plans ever panned out.

[Zachary Crockett]

But in the decades following World War II, researchers started to wonder if botulinum toxin might have medical uses. And in the late 1970s, an eye surgeon named Alan Scott thought it might be useful to treat a disorder called

[Narrator/Reporter]

strabismus, which causes the patient's eyeballs to misalign.

[Dr. Steven Williams]

That was the first entry into it being used clinically to make people better.

[Zachary Crockett]

Scott found that injecting extremely small, purified,

[Narrator/Reporter]

non lethal amounts of a certain type

[Zachary Crockett]

of botulinum toxin around the eye could

[Narrator/Reporter]

temporarily paralyze and weaken the orbital muscles and fix the problem. He named this drug Oculinum.

[Zachary Crockett]

It was a therapeutic breakthrough, one that

[Narrator/Reporter]

Dr. Jean Carruthers witnessed firsthand, and she found it emotional.

[Dr. Jean Carruthers]

I remember one patient who came in, led by his wife, by the hand. He couldn't open his eyes. And three days later, he sent me a picture of himself driving. Sorry. Driving his red convertible. Yeah, sorry.

[Narrator/Reporter]

Carruthers is a clinical professor of ophthalmology at the University of British Columbia in Vancouver. She worked closely with Dr. Scott in the early 1980s before starting her own practice with her Husband, a dermatologist.

[Zachary Crockett]

She used botulinum to treat optical problems. But one day she discovered it had other benefits.

[Dr. Jean Carruthers]

One of my patients got angry at me. She said, you didn't treat me here, pointing at her medial brows. And I apologized to her and said, I'm so sorry. Didn't think you were spasming there. And she said, I know, I know I'm not spasming there, but every time you treat me there, I get this beautiful untroubled expression. And the penny dropped because my husband told me how difficult it was to treat these frown lines.

[Narrator/Reporter]

Carruthers began studying the cosmetic use of botulinum toxin.

[Zachary Crockett]

The first test subject was the receptionist in her office.

[Dr. Jean Carruthers]

She had really impressive frown lines. By 3 o', clock, they were pretty severe. We treated her and you could see this amazing difference.

[Zachary Crockett]

In 1991, Dr. Scott sold Oculinum to

[Narrator/Reporter]

the pharmaceutical company Allergan.

[Zachary Crockett]

The following year, the treatment was renamed Botox.

[Narrator/Reporter]

It took Allergan another decade to secure FDA approval for cosmetic use.

[Zachary Crockett]

And even then, sales weren't so hot. It was hard enough to sell the

[Narrator/Reporter]

public on the merits of a watered down neurotoxin that once killed sausage enthusiasts. But Botox had another problem too.

[Dana Berkowitz]

Early on, there was a stigma that Botox froze your face.

[Zachary Crockett]

That's Dana Berkowitz.

[Narrator/Reporter]

She's a sociologist and the author of the book Botox Changing the Face of America.

[Dana Berkowitz]

They really wanted to get around that stigma and show that, well, if you just use a little bit of Botox, you can still express yourself. It was couched in this post feminist narrative of, you know, doing it for you.

[Narrator/Reporter]

Allergan embarked on an advertising campaign to

[Zachary Crockett]

convince millions of people, mostly women, that

[Narrator/Reporter]

Botox could be a form of aesthetic liberation.

[Capital One Sponsor Narrator]

Talk to your doctor about the one, the only Botox cosmetic. Freedom of expression. That's what it's all about.

[Zachary Crockett]

This kind of messaging worked. Between 2000 and 2015, Botox sales jumped tenfold. In 2020, Allergan was bought out by

[Narrator/Reporter]

another pharmaceutical firm, Abbvie.

[Zachary Crockett]

And today, global sales of therapeutic and

[Narrator/Reporter]

cosmetic Botox clock in at $5.7 billion annually. There are now multiple competing drugs on the market, like Dysport, Xeomin and Jeuveau.

[Zachary Crockett]

But Botox is still the undisputed king

[Narrator/Reporter]

of the industry, accounting for around 70% of the market share in its category.

[Zachary Crockett]

That's largely thanks to ongoing ads that

[Narrator/Reporter]

target the everyday woman.

[Tanya (Botox User)]

Hi, my name is Tanya. I'm 42 years young. I am a mom of nine, and this is like the first thing I've done for me in a really, really long time. My life is still crazy. It's just as full as it was before, just with less lines.

[Zachary Crockett]

Getting regular injections to treat wrinkles has become much more culturally acceptable, even for men, and you don't have to look

[Narrator/Reporter]

hard to find a place to get treated.

[Dana Berkowitz]

There's medical spas in every single suburban small town now across the country who promote Botox injections. It's really everywhere.

[Zachary Crockett]

That's coming up.

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[Charles Schwab Sponsor Narrator]

This episode is brought to you by Charles Schwab. Is there a right time to sell a stock? Are you taking the right risks with your portfolio? Financial decisions can be tricky, and often your own cognitive and emotional biases can lead you astray. Financial Decoder an original podcast from Charles Schwab can help join host Mark Reape as he offers practical solutions to help overcome the cognitive and emotional biases that may affect your investing decisions. [e-mail] FinancialDecoder

[Zachary Crockett]

There are two main ways

[Narrator/Reporter]

that our faces Age 1 is through

[Zachary Crockett]

the natural loss of the protein collagen

[Narrator/Reporter]

this causes our skin to sag over time. The other way is through repetitive facial movement.

[Zachary Crockett]

By smiling and frowning in the same

[Narrator/Reporter]

ways, year after year, we etch wrinkles into our skin. Botox works on the second kind of wrinkles. It binds to nerve receptors that temporarily paralyze a targeted muscle.

[Zachary Crockett]

But it doesn't work on the first

[Dr. Steven Williams]

kind of when people have nasolabial folds. Those are kind of the folds along your cheek, or what we call marionette lines, which are sometimes those wrinkles that are on the corners of your mouth down to your chin. Botox is terrible for those because they're not caused by a lot of muscle activation.

[Zachary Crockett]

Again, that's Dr. Steven Williams, who runs

[Narrator/Reporter]

a plastic surgery practice in California.

[Zachary Crockett]

For those wrinkles caused by collagen loss, surgeons usually recommend dermal fillers.

[Narrator/Reporter]

These are injections of synthetic or natural polymers that plump up the skin.

[Dr. Steven Williams]

But when we think about wrinkles on your forehead, when you kind of raise your eyes in surprise because someone says something really weird, those wrinkles are caused by the muscles in your forehead contracting and creating these lines in your skin or the wrinkles between your eyebrows when you are confused, temporarily paralyzing those muscles decreases the wrinkles.

[Narrator/Reporter]

Medical practitioners typically buy Botox wholesale from a medical distributor.

[Zachary Crockett]

A single vial of cosmetic Botox might cost them between 350 and $700. That one vial contains 100 units, which might be enough for a dozen treatments,

[Narrator/Reporter]

or for one big one for a

[Dr. Steven Williams]

brow lift, where you inject a little bit on the side of the eye. You know, those doses are relatively six to eight units for people who are trying to get reduction in their platysma. So those neck muscles that give people some of the banding on the neck dosages can be 50 to 100 units at one setting. The treatment cost itself is usually about double what the cost of Botox is to us. That's typically the markup at most reputable dermatology plastic surgery offices.

[Narrator/Reporter]

There aren't any federal regulations around who can administer Botox.

[Zachary Crockett]

In some states, you can find treatments offered not just by plastic surgeons and dermatologists, but by estheticians and even dentists. Across the country, thousands of medical spas

[Narrator/Reporter]

have popped up offering Botox treatments for lower prices than most plastic surgeons charge.

[Zachary Crockett]

And they're lucrative enough that private equity

[Narrator/Reporter]

firms have started buying them up. And consolidating the industry.

[Dr. Steven Williams]

There has been a little bit of a race to the bottom. You know, a lot of these med spas, as they proliferate, it's a pricing thing, and they'll say, well, you know, we'll do $4 a unit or $5 a unit.

[Zachary Crockett]

As Botox has become more accessible, so

[Narrator/Reporter]

too has counterfeit Botox that can be readily found on the Internet.

[Zachary Crockett]

These fakes can be hard to tell

[Narrator/Reporter]

apart from the real thing.

[Zachary Crockett]

They might contain no botulinum toxin at all, or they might contain far more

[Narrator/Reporter]

than the proper dosage.

[Zachary Crockett]

Federal agencies have identified more than 2,000

[Narrator/Reporter]

instances of counterfeit Botox being sold by medical professionals in the last decade.

[Dr. Steven Williams]

These products are manufactured under different regulatory scrutiny in other countries. And because there's less regulation around it, a lot of times it's less expensive. They're trying to make money, and they don't necessarily care about people. The problem is that the treatment itself is a medical procedure and has risks. And then the medication, even when sourced appropriately, if you don't know how to use it, has risks.

[Zachary Crockett]

While plastic surgeons charge a premium for trustworthy service, a single visit for Botox

[Narrator/Reporter]

is still a lot less lucrative than surgery.

[Zachary Crockett]

A frown line treatment might cost $500

[Narrator/Reporter]

or so, compared to $10,000 or more for a facelift.

[Zachary Crockett]

But for most people, the effects of

[Narrator/Reporter]

Botox wear off in three to four

[Zachary Crockett]

months, so you have to keep going

[Narrator/Reporter]

back to maintain your desired look.

[Zachary Crockett]

That means that offering Botox provides doctors like Williams with a form of recurring revenue.

[Dr. Steven Williams]

If we're just doing surgeries, we might see our patients for some liposuction or breast augmentation in their 20s, and then potentially after they've had children, maybe a tummy tuck, and then maybe as they get older, maybe blepharoplasty or facelift. Botox allows a continual relationship with patients over time. We have patients using Botox for almost 20 years now.

[Zachary Crockett]

People are getting started with Botox at

[Narrator/Reporter]

younger ages than they used to.

[Zachary Crockett]

Botox was originally marketed to women in their 50s and 60s. Today, many new patients are women in their 30s, 20s, or even late teens. They're getting Botox before wrinkles even form. Dana Berkowitz, the sociologist, says this has

[Narrator/Reporter]

a lot to do with social media.

[Dana Berkowitz]

They interviewed women between the ages of 20 and 30 who had used Botox. Every single one of them said that social media was the culprit. We have targeted ads. You have young influencers who are getting free procedures from clinics and medical spas so that they document the procedure on their feed. There was this idea that you used to get beautiful in private, and now you got beautiful in public for the world to see.

[Zachary Crockett]

Some of the women that Berkowitz interviewed

[Narrator/Reporter]

also expressed an economic justification for getting Botox.

[Dana Berkowitz]

I interviewed three broadcast journalists. All of them spoke about the importance of using Botox to preserve their appearance. Some people also talked about writing it into their contract that they would be able to get Botox for their career preservation. A lot of people said, you know, my face is my business card. I need it to preserve my appearance.

[Zachary Crockett]

Dana Berkowitz has gotten Botox injections herself, but she also has some reservations about it because all of those Botox faces

[Narrator/Reporter]

we see on Instagram, TikTok and local news stations have introduced new insecurities around the natural process of aging.

[Dana Berkowitz]

Does Botox work? Yes. Does Botox make people look and feel better? A lot of the time? Yes. Is this still problematic? Absolutely. Every single time I use Botox, I feel like I am individually failing at feminist ethics. It transforms our perception of what is normal, of what is beautiful, of what an aging face should and does look like.

[Zachary Crockett]

Dr. Steven Williams has mulled over that conundrum many times.

[Dr. Steven Williams]

Unfortunately, there's bias to pay, there's bias to access to resources. There's bias to finding a mate or a life partner. I think that it's important to recognize that society puts enormous pressure on people to look a certain way. Some people choose to respond to that, saying, I'm going to age gracefully and not fight it. But the flip side is that is what society is. People really like the things that Botox is able to do for them.

[Zachary Crockett]

For the economics of everyday things, I'm Zachary Crockett. This episode was produced by by me

[Narrator/Reporter]

and Sarah Lilly and mixed by Jeremy Johnston.

[Zachary Crockett]

We had help from Daniel Moritz Rapson.

[Dr. Jean Carruthers]

I want to tell you right now, I haven't frowned since 1987.

[Zachary Crockett]

The Freakonomics Radio Network the Hidden side

[Tanya (Botox User)]

of Everything

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[Walmart Business Narrator]

Who knew Walmart business could help a bustling school district stay on budget? Principal Lewis knew. He uses Walmart business to easily get the items his elementary school needs.

[Principal Lewis]

Our tax exempt status works online and in store. And with our tight budgets, they have everything we need at prices.

[Walmart Business Narrator]

I love expense management tools help him stay on top of what he's spending

[Principal Lewis]

I keep track of hundreds of things every day. Jenny, get out of there. Thankfully, Walmart business lets me keep track of all our expenses in one place. Aaron, don't eat that makeup.

[Walmart Business Narrator]

Michael, it's Walmart built for your business. Who knew? Eligible organizations Additional terms apply this episode

[Charles Schwab Sponsor Narrator]

is brought to you by Charles Schwab. Is there a right time to sell a stock? Are you taking the right risks with your portfolio? Financial decisions can be tricky, and often your own cognitive and emotional biases can lead you astray. Financial Decoder, an original podcast from Charles Schwab, can help join host Mark Reape as he offers practical solutions to help overcome the cognitive and emotional biases that may affect your investing decisions. [e-mail] financialdecoder.