Table 2 Themes, Subthemes, and Illustrative Quotes from Interview Transcripts

Social disadvantage:

“I think my practice reflects what we know in the general population which is that as you go down the income scale and down the scale of housing security and other forms of social security that type of risky behaviour tends to increase. But I think that is absolutely true in my practice as well. So (individuals with) major mental health diagnoses are much more likely to smoke, people who are living in poverty who experienced homelessness, people who have experienced trauma, people who experience other forms of social pressure like racism, people who are racialized, people who…you know identify as LGBT or trans. I mean I’d say people from any one of these groups have a higher likelihood of smoking.” (FP10)

“They’re all doing work hours, so people who work shiftwork, people who are taking care of children, all of these sorts of folks who are generally going to be less socially advantaged. These people are not able to take off time because they’re not necessarily protected in their jobs or have job security. These folks are not going to come to my office with all this information saying I want a CT for lung cancer screening.” (FP11)

“For socially vulnerable patients (…)I need to be more attune to them in terms of how they can be notified of their appointments so they’ll have phones that sometimes are connected, sometimes aren’t. Some of them much prefer to have appointment notifications through email because they can. They have their computers and they can check email at like the shelters they’re staying at, whereas for others, that won’t work for them at all. So it’s hard because there’s not like one answer that works best for this particular population.” (FP2)

Clinical encounter:

“They only seek medical care episodically in crisis that they’re often challenging to accept into family practices because of time restrictions. Our model of seeing patients isn’t very amendable to super complex patients who have health complex needs as well as socio-economic needs so it’s hard to build a relationship. It’s hard to keep appointments where you need to be at an appointment at a certain time.” (FP5)

“I mean our appointments are 15 min usually. And I mean we try to practice patient-centered care. So for instance, I had somebody who had a major medical issue and I’m quite focused on managing that. Making sure that she doesn’t go into liver failure, but her priority coming in is to deal with housing issues, and so those are two large topics and therefore like bringing up that she’s due for a screening test there’s not always time and I’m distracted by these other big issues that I think are potentially more urgent. So this distracts my attention.” (FP8)

“If there was maybe some type of patient navigator who is quite familiar with the system and was a bit of a quarterback to coordinate the appointments and help people with transit and putting the pieces together and identifying the gaps to bring to the social worker or the teams that might help.” (FP4)

“At a Community Health Centre they have social workers and like they are part of a team. So if you’re in a primary care model where you’re part of a team it is possible to help a patient get a little bit more stabilized, so if it’s a mental health issue than you know have them either see a psychiatrist If it’s social situation then yeah, I wouldn’t manage that myself but I would refer to the social worker and we have social workers.” (FP1)

“Maybe hooking them up with a social worker or a counsellor …(and) maybe having a coordinator involved just to make sure they make their appointments.” (FP7)

Equity-oriented health care:

“I really try to help people understand what an addiction truly is. I’m like this is not a judgment on you that you’re still smoking. It’s not because you’re lazy or just don’t have enough willpower, like when you started smoking that early in your life you know it really changed your brain.” (FP3)

“I think probably a combination of boredom, of culture, of you know, it (smoking) is something that’s done in peer groups so I think that it’s more socially acceptable.”(FP5)

“Factory workers, people who work in a warehouse, in most of these kinds of jobs it is just the acceptable way to take a break… Some people are smoking because they need to stay awake because they have a very long-distance drive … They don’t usually go anywhere (with smoking cessation) until they change their job.” (FP9)

“I’d say that in our first few encounters I noted the smoking history. I gently flagged it as an issue but I spent very little time on it in our first few encounters. Well really I mean first two years of knowing him because we were really working on stabilizing all the other things going on in his life and those were clearly his priorities and clearly my priorities; right. I didn’t think the smoking mattered all that much in the context of everything else that was going on for him which was far greater threats to his health than the smoking. Progressively over time his social situation really stabilized in very significant ways. He became housed, he got on ODSP so he got steady income…the conversations around smoking just started to just take up more time in our interactions progressively and you can probably almost put a like linear graph to that in terms of how much time they were taking up and you could just sort of see smoking rising up as an issue in terms of the list of priorities as other things kind of stabilized.” (FP10)

Improving health outcomes:

“Taxi chits … phone call reminders, you know because often we get patients who will miss my appointments.” (FP8)

“Different language literature, pictorial designs that makes it easy to understand. Maybe a navigator in different languages. Community programs. Community websites.” (FP9)

“I think automating it where possible so that the smoking history, anyone with a heavy smoking history will be automatically flagged.” (FP6)

“Compensation for physicians when we make phone calls or do emails cause it’s not just outside of our work time like it cuts into our work-life balance, but we do it, but I think we’d do a little bit more of it maybe if there was some sort of acknowledgement.”(FP8)

“How likely are they (low income patients) to tolerate chemotherapy or treatment or surgery? You know going through those very, very intensive treatments or follow ups; and it’s not easy when they’re coming home to a shelter bed or they’re coming home and they’re choosing. A lot of the time they have to make choices between food and bills and those sort of costs are very, very significant. So, I think one question is are we screening them enough? And the other question is are we supporting them enough to get treatment? So, even if I had, if I was able to get everyone screened at the point of detecting lung cancer what then would happen to these patients?” (FP11)

“Help people get housed and help them get a better income quite honestly. I mean I don’t think the answer lies in tweaks in a screening program. I think that these are systemic issues and I think it would be a mistake, and I think it would reinforce the systemic problems that we have to sort of say you know, we can finance this population in how we offer this program….(and create) a diversion of resources to this type of screening (and away from) what’s most important for building a foundation for good health.” (FP10)