In this occasional series in conjunction with the SSA’s journal Addiction, we record the views and personal experiences of people who have especially contributed to the evolution of ideas in the journal’s field of interest. Professor Thomas Babor is Chair of the Department of Community Medicine at the University of Connecticut School of Medicine. In a long and distinguished career in addiction research he has worked on the development of typologies for alcoholics, screening tools for drug and alcohol use, and treatment of cannabis use disorders. He led the project teams that summarised effective policies in the alcohol (Alcohol: No Ordinary Commodity) and drug (Drug Policy & The Public Good), published with the support of the SSA.
Photo: Kaisa Rautaheimo HS
ADDICTION (A): You were born in New York City during the closing years of the war. What was it like to grow up in post-war Queens?
Thomas Babor (TB): New York City in the 1950s was part of a post-war boom where the older European immigrant families were rapidly being absorbed into the American melting pot. My grandparents were Czech, and my parents’ large families, which grew up in Manhattan, were migrating to Queens and Long Island. The Catholic Church was strong and protective of its European families, so my life revolved around the local parish and the parochial schools I attended. The education system was excellent, even for working class kids. I went to primary school in Queens, secondary school in Brooklyn, and college in The Bronx, so I spent a lot of time traveling around the city on the subway. In high school and college I got a heavy dose of the Liberal Arts and more than the trappings of a classical education. I am grateful for that. Another thing I learned from my formative years in gritty and grimy New York was that there had to be something better than the urban sprawl that was growing all around me. By the time I finished college, I was ready to leave, especially after reading Joyce, Fitzgerald and Hemingway. I wanted to see Europe, and then go West.
A: Were either of your parents interested in medical practice or science?
TB: My father was a civil engineer and my mom was a full-time homemaker. With four kids in six years, she had her hands full. My father was the youngest of eight children, the only one to graduate from college. He owned a construction company whose business offices were located in mid-town Manhattan. I can remember visiting construction sites with him around the city, and interacting with the laborers who worked for him. One of his foremen would let me steer his truck sitting on his lap when I was seven years old. My parents were very supportive of higher education, but my mother warned me that if I pursued psychology I might lose my faith. She was right, as usual.
A: How old were you when you knew you wanted to go into psychology, and how did you reach that decision?
TB: I knew I did not want to go into my father’s construction business. I liked the social sciences, and at one time considered becoming a medieval historian. I decided to go in a more practical direction after taking some initial courses in psychology. I found I liked to do research even as an undergraduate. My professors not only taught me well, they also encouraged me to get my Ph.D., the “union card” as they called it. So the decision was reached in part through a process of eliminating career paths that were not appealing, and finding one that had good job prospects and also satisfied my social science interests.
A: Arizona is a long way from New York – how was the transition?
TB: I applied to six graduate programs in social psychology, but was accepted to only one. It turned out to be the best one for me. The University of Arizona was expanding its graduate programs rapidly, recruiting students from all over the country. I transitioned out of New York quite easily because the City at that time had become an unwelcome, even inhospitable place: high crime, racial tension, polarized politics. Arizona was like a dream. The Sonoran desert was beautiful, The drug epidemic was just getting started with experimentation going hand in hand with political protests, women’s rights, the anti-war movement, civil rights. It was there that I got interested in substance abuse. At first I wanted to do my dissertation on marihuana but my department chair in the doctoral program thought it would be too controversial and suggested I do my research on problem drinking. That was when I read EM Jellinek’s The Disease Concept of Alcoholism and my career in research really got started.
A: You went to Harvard for further training in 1981. Can I assume then you couldn’t get into Stanford, or do you just have bad judgement?
It was at a cocktail party at the U of A where one of the faculty suggested that I should apply for a post-doctoral research fellowship at Harvard Medical School. I did, and perhaps on his recommendation, I was accepted. I then asked for a delay in starting because I had decided I needed to go abroad to fulfill my fantasy of becoming an American expatriate in France. I enlisted a French native to compose for me a perfectly crafted letter that described my intention to conduct definitive research on types of alcoholics and the nature of alcoholism in France. I sent the letter to many universities. One of them referred my inquiry to the largest hospital in France for alcoholics, where they invited me to come, live and work on a substance stipend as a “student nurse.” The position gave me the opportunity to do my research on their alcoholics. Upon my initial arrival after the long journey, I was so disheveled and my spoken French so poor that they started to admit me as a patient. After I verified that I was the invited American visitor, they moved me in with the staff and I got on with my research. It was a fantastic experience, both professionally and personally.
A: Who were your mentors in your graduate and post-doctoral training and what did you learn from them?
TB: My mentor in the psychology program was Sal Zagona, a social psychologist who studied cigarette smoking in Mexican-American, Native American and European American youth. I did my masters thesis on his data, and my doctoral dissertation was on alcohol expectancies. By the time I got to Harvard for my post-doc I was assigned to Jack Mendelson, who had just returned from the US National Institutes of Health in Washington, DC, to chair the department of Psychiatry at Harvard Medical School and Boston City Hospital. Jack had done pioneering work with Nancy Mello on alcohol self-administration in chronic alcoholics, and their operant research model was soon applied to marihuana and heroin. I was able to incorporate my social research ideas into his biobehavioral research projects on the addiction cycle in heroin addicts and to study the social and psychological effects of marihuana. One thing I learned is that you can do a lot more research if your mentor has large grants than if you have to design and conduct a study yourself without funding. I immediately had extraordinary opportunities for publishing in good quality journals, and for networking with leaders in the emerging field of addiction studies.
A: In 1971-1972, you received training in “social psychiatry”. Many people today would not know that term – what do you think the contributions of it were and why didn’t it continue to grow?
TB: At that time there were competing paradigms developed to explain mental disorder and addiction, one of them built around the “Neo-Kraepelinian Revival” in psychiatric diagnosis, subsequently incorporated into the dominant biological psychiatry model, the other, a “social psychiatry” model that was supported by radical psychiatrists, behavioral psychologists and social epidemiologists in the addiction field. As I now tell my graduate students in my psychiatric epidemiology course, biological psychiatry won the war but the social psychiatry critique of categorical diagnoses and underlying biological causes is still valid.
A: What were your main activities and collaborators at Harvard during your years there?
TB: Working with Jack Mendelson and Nancy Mello in Boston provided enormous opportunities not only for collaboration but also for meeting the people who later became the main innovators in the addiction field. My work on types of alcoholics began there, as well as my research on the social effects of alcohol, marihuana, and work on psychiatric interviewing and diagnosis. Roger Meyer, a young psychiatrist with a gift for research management and an openness to ideas, was brought in as a collaborator, and people like Griffith Edwards, Jerome Jaffe, and Lee Robins became familiar faces to a semi-outsider like me.
A: What drew you to the University of Connecticut? Who have been some of your significant collaborators and mentees there?
TB: When Roger Meyer moved to the University of Connecticut to become chair of Psychiatry, he asked me to become part of the Alcohol Research Center he had begun to build. He recruited Michie and Victor Hesselbrock as well as Jerry Jaffe, Ron Kadden, Mark Litt, Ned Cooney, Ovid Pomerleau and a variety of other addiction researchers, and in the process created a new concept for an addiction research center. The center was academically-based, linked to clinical facilities providing access to patients with addictions. It was designed to have close proximity to students in medicine, psychology and psychiatry, and provide postdoctoral research training opportunities.
A: How did the work on the AUDIT and ASSIST come about, and what do you think the impact of reliable screening measures has been on clinical practice in the U.S. and abroad?
TB: Soon after moving to Connecticut in 1982, I was asked by Roger Meyer to work with Lee Towle, a masterful international program director at our center’s main funding agency, the National Institute on Alcohol Abuse and Alcoholism. NIAAA had been asked by the World Health Organization to nominate one of its centers to have US involvement in the development of a new international screening test. After attending the initial meeting, I was convinced that international collaboration could produce something of value. I participated in the initial six nation study to develop the AUDIT, and came up with the acronym on a 14 hour flight back from a collaborators’ meeting in Sydney, Australia. The AUDIT was so successful after its initial debut in 1989 that a few years later Maristela Monteiro, a WHO scientist at the time, asked me to help them develop a new test that covered all psychoactive substances. Using the same process of cross-national consultation, expert committee meetings, pilot testing in multiple countries, a full multi-site validation study, and a randomized trial of brief intervention, the ASSIST was brought to market even more rapidly than the AUDIT. The two screening tests form the core of a package of users manuals and training materials, and they gave impetus to the psychometric and clinical research needed to create a credible case for screening and brief intervention in primary health care. The approach has been one of the most successful examples of translational research in the addiction field, in that it led to the creation of demonstration programs throughout the world, and the eventual adoption of alcohol screening as a standard of care. It is remarkable what a small investment of funds by a United Nations agency like WHO can accomplish at a critical moment in time, using public health concepts and international collaboration as a vehicle.
A: Debate continues on whether screening, brief intervention and referral to treatment is beneficial and to whom. You have contributed to the literature in this area, what is your read on what we know?
TB: The evidence for a small benefit from brief intervention after alcohol screening is well established, but that is not the only or even the main contribution of screening, brief intervention and referral to treatment (SBIRT). The development of efficient screening procedures has changed attitudes within the medical profession, and that has begun to change the norms about heavy drinking in the general population. That’s why there is now a need to bring SBIRT to the population level by combining community-based clinical programs with social marketing of SBIRT and the delivery of abstinence and moderation messages through the mass and electronic media. Unfortunately, the promotion of drinking norms and “responsible drinking” messages are currently controlled by the alcohol industry, and it will take years to change that for the better. I think SBIRT concepts embodied in brief intervention could compete with industry messages if we invested more in social marketing guided by population science.
A: You have led or co-led multiple international book projects that were intended to influence alcohol policy for the better? Do you see any evidence that they did?
TB: The book projects on alcohol policy grew out of the seminal monograph (Alcohol Control Policy in Public Health Perspective) that Kettil Bruun, Griffith Edwards and colleagues wrote for WHO in 1975. That was a book that certainly changed my career for the better, and it was the main resource for national and international policymakers until Edwards et al published Alcohol Policy and the Public Good in 1994. Subsequent iterations included two editions of Alcohol: No Ordinary Commodity (2003, 2010) and an adaptation of the epidemiological storyline to drug policy and now gambling policy. The books have sold more than 10,000 copies and have been translated into more than 10 languages. They are widely cited in research and policy debates, which means somebody is reading them. In addition to providing scientific and moral support to policy advocates throughout the world, the books represent the realization of an ideal, often ignored in professional societies and funding agencies, that we as addiction scientists have an obligation to make our research relevant to policymakers and public health policy. The books were successful because of the creativity that comes from collaboration among co-authors who happen to be career scientists with different points of view.
A: You spent many years studying the treatment matching hypothesis, which seems to have drawn less interest in recent years. Do you think that is a welcome development, or is there more yet to be learned from pursuing treatment matching studies?
TB: Project MATCH, UKATT, COMBINE, and other multicenter trials like the VA Effectiveness Study, tested the validity of the “Technology Model” of therapeutic change, which postulates that patient attributes and treatment process elements, respectively, constitute moderators and mediators of change in drinking and drug use following treatment. The studies showed that matching to therapeutic orientation is not an essential ingredient to substantially enhanced outcomes, as previously believed. They also indicated that the mediational mechanisms underlying several of the most popular therapies (e.g., MI, CBT) are different than what is suggested by their proponents. The inability of the Technology Model to explain, much less improve, the effectiveness of addiction treatment suggests the need for a new paradigm. It may be more fruitful to look for matching in larger populations at the level of communities or treatment systems, where a wider range of settings and therapeutic interventions can be evaluated. More importantly, MATCH and our Cannabis Treatment Project showed that the anticipation of treatment accounts for much of the initial change in substance use. That suggests we should devote more attention to studying the determinants and facilitators of treatment access, rather than pursuing the rather fruitless search for new therapeutic agents that often prove to be no more effective than the old ones.
I hope the personalized medicine approach, using the tools of neuroscience and genetics, does not lead us into the same trap of dedicating significant scientific resources to the pursuit of a flawed theory. I believe we learned a lot from these trials, but we unfortunately neglected to reject our belief in flying saucers when the prophecy failed. We should have redoubled our efforts to consider the implications of the findings for the organization of treatment systems that could be matched to population caracteristics, rather than returning to the narrow focus on individual differences and homeopathic doses of pharmacotherapy and psychotherapy. We shape our methodological tools, and thereafter our tools shape us. We need to do a better job of asking the right questions, instead of formulating questions that can only be answered by our favorite tools.
A: Let me ask you the same question again with reference to alcoholic typology research, to which you were a major contributor.
TB: The typology research that started my career was inspired by Jellinek’s concepts of culture-bound syndromes of alcohol dependence, which molded different types of alcoholics because of the predominant drinking patterns conditioned by environmental circumstances. I think the typology is still valid as a way to understand how cognitive, behavioral and physiological aspects of alcohol dependence are manifested within a drinking culture, and how the broad interactions among different etiological elements can be treated. Unfortunately, the treatment implications do not fit our current “Technology Model” assumptions, so we tend to ignore the fact that gamma alcoholics are much more difficult to treat than delta alcoholics, and the former require enormous resources that go beyond what we offer in our circumscribed treatment programs, and the latter require little more than a therapeutic nudge.
A: You have done seminal research on cannabis use disorder and its treatment. What are your hopes and fears about the public health impact of cannabis legalization in parts of the U.S.?
TB: Because cannabis has been so readily available in many Western countries since the 1970s, the current wave of legalization is not likely to create new epidemics that are any worse that what we’ve seen in the 1970s and 1990s. But the entry of big money, sophisticated marketing and government dependence on tax revenues is likely to increase the prevalence of marihuana dependence in young adults and older people. In the Marihuana Treatment Project that we conducted for the US Substance Abuse and Mental Health Services Administration, we learned a lot about what regular “toking” does to a man and a woman. It is not a pretty picture, and the syndrome driving daily use can be as insidious as opioid or alcohol dependence. I think legalization will be quite welcome in our current consumer society where a “legal high” is just another commodity, and then it will take decades to clean up the public health ramifications.
A: You were the Deputy Editor of Addiction for many years and are now Editor-in-Chief at the Journal of Studies on Alcohol and Drugs. You also co-edited a book about scientific publishing. What did those experiences teach you about our journals and how they operate?
TB: Those experiences taught me very little beyond what I learned from my friendship with Griffith Edwards, who literally “wrote the book” on scientific publishing in the addiction field. Griffith saw journals as a marketplace for ideas, not just a place to publish research papers. He saw the journal as an extension of the meeting rooms of the Royal Academy in 17th century London, a place where thoughtful people gathered to ask questions, debate issues and solve problems, not a place to publish trivia based on statistical significance. He showed that a journal could become a living social organism, and that it could set the standards for a field of inquiry.
A: If you could change the basic framework of scientific reviewing and publishing in one significant way, what would it be and why?
TB: Like many fields of modern science, local governance by the invisible college of reputable scientists, what we call the peer review system, is being eroded by the emergence of for-profit online entities that are neither journals nor scientific. Rogue journals run by Predatory Publishers are going to force us to improve the quality of our journals, and provide legitimate outlets to less competitive papers that nevertheless have something to say. I would like to see a certification process for addiction journals that can demonstrate quality peer review and high ethical standards. We also need a way to prevent junk science, which is increasingly being published in non-peer reviewed journals with addiction-sounding names, from polluting the science base.
A: You have openly worried that the alcohol industry has found ways to infiltrate public health research and policy on alcohol. What are you concerns and what could be done about them?
TB: As the alcohol industry has become more globalized and more concentrated into a smaller number of transnational corporations, they have become a engine of expanding alcohol consumption in the developing world. The Perfect Storm of mass marketing, weak alcohol control policies and an emerging youth market will create the equivalent of the tobacco-related disease epidemic of the late 19th century, which will take 20 to 30 years to reverse. Their attempts to neutralize, if not control the science base has followed the example of the tobacco industry, with similar results. Unless our scientific colleagues and research societies eschew funding from the alcohol, gambling and pharmaceutical industries, we are going to see a lot more of the dissention that has characterized the field of late. We know that industry money, whether it comes from tobacco, asbestos, gambling or pharmaceutical companies, can bias the research agenda, create dissention in a field of science, and influence the outcomes of research papers and literature reviews. Competing interest declarations are not sufficient. We need independent funding sources and independent scientists.
A: You have been a chair of community medicine department for decades. What has that taught you about nurturing junior academics?
TB: Academic departments are one of the main ways to identify, recruit and nurture addiction scientists, but the corporate model that currently drives universities and academic medical centers has made that more difficult. Public health is a great field to introduce idealistic students and junior faculty to the rewards of addiction science. Research centers attached to academic public health departments have the potential to improve the science base for alcohol, drug and gambling policy, but there needs to be a better vision for this course from our science policy leaders, the kind of vision that led to the creation of an addiction science infrastructure and workforce in the 1970s. The biomedical model underpinning the support for addiction neuroscience and genetic research needs to be complemented by an equally strong investment in the population science of addiction. If the same resources were invested in population approaches, we would be much better prepared to address the needs of policymakers, who are not really finding the answers they seek to the pressing policy questions of the day.
A: Do you ever envision yourself retiring, or do you expect to keep working at your remarkable pace for many years to come?
TB: Retiring? I’ve been having so much fun I never thought I was actually working. I suppose I will wind down eventually but there are a few things I want to do before a become a full-time Gentleman Farmer in Maine. For one, I want to set up a certificate program for training addiction scientists internationally. I also want to meet the minimal criteria for sainthood in the Catholic Church (two miracles) by discovering two policies that reverse binge drinking and drug epidemics worldwide.
A: To close on a personal note, you are a big fan of Groucho Marx. Which of his characters is your favorite, and why?
TB: That has to be Quincy Adams Wagstaff, the president of Huxley College, in the 1932 Marx Brothers film, Horse Feathers. Besides being a brilliant satire of academia, there are many references to Prohibition. Chico Marx is an “iceman” who makes home deliveries of bootleg liquor from a local speakeasy, and Groucho, an impostor posing as a professor, gives a nonsense lecture on cirrhosis of the liver. The most important lesson here is that academic institutions, because they can be pompous, bureaucratic, and pretentious, are fertile grounds for people who enjoy creating chaos.
Thomas Babor was in conversation with Professor Keith Humphreys
The interviewee has provided an annotated bibliography of his work, available here
The full, unedited transcript of their conversation can be found here
An audiorecording of the conversation can be found here
The opinions expressed in this commentary reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the Society for the Study of Addiction.