Smoke gets in your eyes
You are working with a client / parent of a client who smokes heavily. Whether you feel you want to mention it – or feel very strongly that you don’t – to what extent is such lifestyle choice and information the responsibility of a speech and language therapist?

Roger Newman considers the following scenario:


s a speech and language therapist you come into contact with people who smoke, whether clients or their parents / relatives. You may even smoke yourself. Whatever the situation, there will be times where you ask yourself if dissuading someone from smoking is the right thing to do, and if it’s your role. While the number of people who smoke has gradually declined it still exists, as do smoking related illnesses - stroke, heart disease and cancer to name but a few. Many smokers take the attitude of “It’ll never happen to me”, but it can, it does and, if they continue to smoke, the chances are significantly increased. When individuals smoke it’s their life, their choice and often their enjoyment. They may even understand the implications and accept the risk. If they want to smoke, who are you to tell them not to? As a health care professional you may think you’re not being caring if you don’t try to help. If you are a smoking cessation officer this will be in your job description but as a speech and language therapist it probably isn’t. Yet smoking doesn’t just affect the individual. It has implications for the health and taxation of the wider population, as well as even bigger issues for society when we consider the link between smoking and poverty. We don’t operate in a vacuum; the legislative context is firmly in favour of making smoking socially unacceptable, and the NHS invests in smoking cessation services. Australia has just significantly changed its smoking legislation, meaning all cigarette packets now have to be completely plain with only the brand and product name in standard colour, position, font style and size. Tax on a packet has also increased by 25 per cent. Raising tobacco excise will generate an extra $6.4 billion over four years, the government says, and the money will be directly invested in hospitals. In the UK the risks of smoking are on the packet, information adverts about smoking are on TV and poster / leaflet campaigns, and smoking in public places is banned. We are all supposed to remind individuals not to stand in doorways smoking – after all, they’re breaking the law. We see smokers standing outside the main entrance to the hospital trying to get out of the rain, but how many of us say something and risk verbal abuse? For many the easier option is just to hold your breath and walk through the cloud of smoke.

BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics require us to “behave with honesty and integrity” at all times (p.14). We are reminded that “poor conduct outside of your professional life may still affect someone’s confidence in you and your profession” (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this new series we think through the sort of everyday events which – although they receive much less attention - also need to be on our ethical radar screen. When you’re on a home visit and the client or a relative starts smoking in front of you it’s their house, their environment and their choice - but it’s having an impact on you. Often local NHS policies regarding passive smoking exist, so you may have the protection of your employer to back you up. Asking someone not to smoke in their own house is a tricky situation to find yourself in, but you have that right - you just need the courage to do it. Dysphonia is definitely one disorder where we can legitimately dissuade the client from smoking and inform them of the risks. If you’re treating a client with a voice disorder, you have a certain obligation to inform them of general vocal hygiene; the dangers of smoking, and the impact it has on the likelihood of their dysphonia improving. You may decide to talk about respiratory control and the impact that smoking has on the respiratory system – this would be valid too. Communicating Quality 3 (RCSLT, 2006) mentions that lifestyle factors may be at the root of a dysphonia’s aetiology. This needs to be addressed and acted upon by both therapist and client for any therapy to be successful. RCSLT (2003) also state one of the key attributes to working as a speech and language therapist is the desire to improve a client’s quality of life. However, another is willingness to accept your own professional limitations. So, do you ‘cross the boundary’ and go one step further to tell them about the additional problems that smoking causes? You may think that bringing heart disease and

unrelated cancer as a result of smoking into a voice therapy session is pushing it a bit far, and may even ruin a well established clienttherapist relationship. As an autonomous professional the choice of whether to take that risk is yours. Other disorders experienced by our clients may be as a result of smoking, and you may think it’s pretty futile informing them of the risks once they’ve had the floor of their mouth removed or had a stroke. They may even become significantly distressed if you remind them that they’ve brought this problem about through their own lifestyle choice. However, what if they continue to smoke? They may find the situation they’re in highly distressing and take solace from smoking. They may even increase the amount they smoke. What if the smoker is the spouse / friend / carer of the client you’re treating? They’re not your client and you have no duty of care for them. Do you have a right or even a duty as a health care professional to inform them of the risks? You may also be extremely concerned for the health of a child if you know the parent is a heavy smoker who does so while the child is in the room. The situation may be quite clear when treating a child with glue ear, as research suggests a highly significant positive association between the duration of effusion and the number of smokers in the household during a child’s first and second years of life (Cook & Strachan, 1999). As a speech and language therapist treating a child with glue ear you could provide this information as a basis for helping to improve the child’s health, their language development, and potentially that of any other children in the household. But are the other risks of passive smoking, or even the possibility that the child may be



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