INTRODUCTION
Drugs are psychoactive substances that lead to addiction, and consuming them irresponsibly creates risks for consumers, families and communities. Whether categorized as legal (caffeine, tobacco, alcohol), prescription (tranquilizers, hypnotics, analgesics), or illegal (marijuana, cocaine, heroin), they constitute a system, with reciprocal interactions that can reinforce their respective effects or act as gateways to other drugs. Alcohol is the paradigm of this system.[1] The 2015 World Drug Report[2] estimated that 1 in 20 persons, between aged 15−64 years, or 246 million people, used illicit drugs in 2013, and 10% of them were addicted.[2] A 2012 survey of 70,000 US participants found similar proportions and estimated that 23.9 million Americans used illicit drugs, and found similar proportions of addiction.[3]

Alcohol and other drug use has multiple links with domestic violence,[4] traffic accidents[5] and various fatal diseases,[6,7] and age of first use is falling.[8,9] Alcohol alone causes 3.3 million deaths annually.[10] WHO defines social drinking as low-risk drinking (≤210 g alcohol per week for men, ≤140 g/week for women), and any use beyond those thresholds is considered harmful.[11] In fact, non-social (harmful) use of alcohol has become the principle risk factor for disease in the developing world and the third in the developed world, after tobacco and hypertension.[12] Patterns of irregular heavy (binge) drinking increase risk of injuries and accidents, as well as certain illnesses, such as neuropsychiatric conditions.[12–14]

Research in the Americas has highlighted alcohol as a significant health risk factor that surpasses tobacco use as the health determinant responsible for the greatest number of disability-adjusted life years lost.[13] Cuba’s alcohol consumption per capita is among the lowest in the Americas, at 5.2 L per year (Grenada’s is highest, at 12.5 L).[10]

Despite its health and social burden,[12,14] alcohol is the most underestimated of drugs on the global, regional and national scales. There is a popular belief that the main risk is its addictive potential, but this ignores its role as a gateway to use of other psychoactive substances, as well as the highly dangerous behaviors of nonalcoholic individuals who exceed the limits of social drinking. And the suffering of loved ones and codependents who constitute the metaphorical group of “passive drinkers” is barely considered.[15]

Cuba’s particular situation must be viewed in its cultural context as a Caribbean nation and as a producer, consumer and exporter of rum. It has also experienced an explosive—and economically much needed—growth in tourism, reinforcing drinking as a form of recreation, a symbol of friendship and a requisite for social life. All this occurs within the context of community tolerance for alcohol consumption far beyond the limits of social drinking.

In 2006, Cuba’s Ministry of Public Health hosted a national workshop on alcohol control with 82 experts from all provinces. The event’s most important product was an updated National Program for Prevention of Irresponsible Alcohol Consumption (PNPUIA),[16] based on the seven policy areas for which Babor and Caetano’s meta-analysis identified the strongest evidence for effectiveness (pricing and taxation, limiting alcohol availability, modifying drinking settings by making bar owners and servers responsible for actions by intoxicated clients, measures to reduce driving under the influence, regulating alcohol promotion, education and social marketing, and services for early intervention and treatment).[14] The updated PNPUIA went into effect that same year and has been operative ever since.[16]

The purpose of this article is to convey reflections derived from my active observation of PNPUIA’s achievements and unreached goals over the past decade, and from research I carried out earlier on how the media contribute to greater consumption of legal psychoactive substances.[17,18] These reflections especially address the prevention of potentially harmful effects of mass media and other components of the cultural milieu that promote unhealthy lifestyles and patterns of alcohol use.

PNPUIA’S OBJECTIVES: PROMOTING HEALTHY LIFESTYLES
Cuban national hero José Marti expressed the moral precept that every human being comes into the world with the right to be educated, and a duty to later contribute to others’ education. I take that to mean that all human beings ought to assume the responsibility of being guides for current and future generations. Only by properly assessing mass media and cultural influences in light of education and value formation can we ensure humanism, honesty, willingness to serve and exemplarity in our educators in all social settings. In keeping with these principles, PNPUIA aims to reduce alcohol use in Cuba, as well as its damaging social and health effects.[16]

ALCOHOL IN CULTURE AND MASS MEDIA
Communication—both interpersonal and mass—influences current and future generations by transmitting patterns of social interaction, knowledge, attitudes, lifestyles, and ethical-moral and aesthetic values. The effects of such communication can be beneficial or harmful, depending on whether it is geared toward instruction and education or left to chance, with the attendant risk of transmitting messages or images with unintended and undesirable consequences.

Communication influencing harmful use of alcohol takes various forms. At one extreme we see systematic distribution of health promotion literature, and at the other, commercial publicity advertising such legal substances. In the middle, there is what I would call naïve advertising: the spontaneous promotion of tastes, habits, fashions and consumption patterns, without any commercial or medical purpose, but in blithe ignorance of the risks involved. Similarly, there is a range of attitudes culturally, from zero tolerance of alcohol in Muslim societies to unconditional tolerance—all too common in the Americas—that tolerates both social drinking and intoxication. In between, there is conditional tolerance, which accepts social drinking without tolerating intoxication, as in some other communities.[19]

Rehm and Monteiro applied a score reflecting the riskiness of drinking patterns (vis-à-vis mortality and burden of disease) in the countries of the Americas and found that none of the countries had a low-risk score, and all had substantial amounts of binge drinking,[13] suggesting a tendency towards unconditional tolerance. This begs the question: What types of benefits could be derived from transforming unconditionally tolerant cultures into conditionally tolerant ones? Could we use mass media and our cultural resources more effectively to prevent harmful use of alcohol?

Some mundane examples come to mind from culture and media: people drinking openly in parks; pedestrians carrying open bottles; television or movie images of alcohol consumption unrelated to the plot (sometimes treated as a necessary preamble to sex, even in marriage). I have observed an increase in frequency of such cases in Cuba and other countries with similar ethnic, historical and cultural roots, such as Spain, Mexico, Panama, Ecuador, Venezuela and others. Research in Chile found that product placement in films and television affected college students’ purchase intentions,[20] and the ubiquity of images of alcohol, both in media and in public drinking, turns the drinking itself into a form of advertising.

And outside of media per se, there are insidious forms of alcohol promotion on jackets, tables, awnings, inflatable bottles, and on trucks distributing beer and rum. Such enticing images trigger the consumer–object need cycle.[21]

When Cuban television and films show negative consumption patterns (such as alcohol being the sine qua non for social activities) and shots of drinks unrelated to the script, these images convey the message that people cannot have fun without alcohol. Although we do not have the option to remove such messages from foreign productions, there is a lot we can do to change Cuban producers’, directors’ and writers’ assumption that their cultural products should reflect the milieu with absolute realism. They continue to operate on that assumption, despite intensive educational efforts to show how pivotal their work is in promoting healthy lifestyles and emphasizing ethical and moral values, by focusing on the positive aspects of everyday life and reducing the emphasis on negative ones, assuming their part of our collective responsibility to promote healthy behaviors.

Untoward effects can occur by commission as well as by omission. Effects by commission occur in families, neighborhoods or dysfunctional communities in which role models display destructive personality traits and lifestyles (which are added to overly permissive attitudes on the macro level). The greatest countervailing force against PNPUIA’s aims, however, could come by omission if we become careless, or—worse—if we undervalue our responsibility as ordinary citizens to contribute to the development of ethical, moral and aesthetic values (indispensable for creating a better world) by setting good examples, sharing adequate information, persuading, and engaging in beneficial osmotic relationships between educators and students.

We need to think systematically about our alcohol culture and look for opportunities to prevent alcohol abuse at every level, starting from the bottom up. For example, a grandmother’s loving offer of a ‘harmless’ cup of coffee and a father’s offer of a drink to his adolescent child, as a sort of rite of passage, is innocent in intention, but establishes a familial and cultural norm that could be the first step to addiction.

This brings me to the importance of educators in inculcating positive social values so necessary for changing our alcohol culture. Such values can only be taught by those who practice them, and who respond to others’ needs as their own. Any resemblance to religious, patriotic, medical, educational, journalistic, rescue, legal or political service is no mere coincidence.[22]

A CALL TO FURTHER ACTION FOR PNPUIA
Preventing the harmful effects of mass media and the cultural milieu is a PNPUIA objective but has been only partially achieved to date. To make further advances, we must broaden our perception of social risk far beyond alcoholism and its complications, and include behavior under alcohol’s influence, codependents’ suffering, and the adverse effects of even social drinking. We have to make clear the true limits of social drinking. We need to ramp up the bluntness of our preventive messages for greater impact, and emphasize the importance of eliminating unconditional tolerance, making every effort to develop community attitudes of zero tolerance of alcohol abuse, and to use media to better advantage to change cultural attitudes toward alcohol consumption.