. 2021 Jul 22;31:40. doi: 10.1038/s41533-021-00252-w

Table 3.

Psychosocial circumstances.

Subtheme	Quotes
Complex social circumstances	“Panicky, breathlessness, distressing childhood, PTSD, difficult life, lots of psychosocial factors, living in a difficult economic environment. Having difficult family situations, sexual abuse, poverty, a million different…. so many different triggers I suppose. Current smoking, ex-smoker, feeling depressed about their continued smoking, unable to stop smoking.” (HP9, Respiratory physician, female)
Financial cost as a barrier to mental health care	“The financial barrier is a problem with these healthcare visits to psychologists, I know when they have the mental health care plan, they have a certain number of visits every year but there’s still an out-of-pocket [cost]. I have some patients who are literally on the bread line, and even though they’re in an affluent area, they’re still in housing commission [public housing]. That’s a big barrier for them financially, because if they have to pay an out-of-pocket expense to see a psychologist, versus putting food on the table for that week, you can see what’s going to win.” (HP13, Community centre nurse, female) “There’s been limitations in how they can access the treatment; often cost-related as well. And caught up in the fact that a lot of the patients with bad COPD often come from low socioeconomic backgrounds and they’re not working, there’s often huge financial strains on them.” (HP7, Respiratory physician, male)
Relationship between smoking, COPD and mental health	“It’s probably the other way around – chicken versus egg – usually their significant mental health problem precedes their COPD, and probably contributes to it because they smoke so much.” (HP15, Respiratory physician, female) “It allays their anxiety – the continuing to smoke, and of course the continuing to smoke makes their lung disease worse and worse, so it’s a vicious circle.” (HP9, Respiratory physician, female) “There’s a group of patients who are still smoking and that’s a really difficult thing to manage as well…. it prevents people from necessarily seeking treatment or engaging in treatment.” (HP7, Respiratory physician, male)

Subtheme

Quotes

Complex social circumstances

“Panicky, breathlessness, distressing childhood, PTSD, difficult life, lots of psychosocial factors, living in a difficult economic environment. Having difficult family situations, sexual abuse, poverty, a million different…. so many different triggers I suppose. Current smoking, ex-smoker, feeling depressed about their continued smoking, unable to stop smoking.” (HP9, Respiratory physician, female)

Financial cost as a barrier to mental health care

“The financial barrier is a problem with these healthcare visits to psychologists, I know when they have the mental health care plan, they have a certain number of visits every year but there’s still an out-of-pocket [cost]. I have some patients who are literally on the bread line, and even though they’re in an affluent area, they’re still in housing commission [public housing]. That’s a big barrier for them financially, because if they have to pay an out-of-pocket expense to see a psychologist, versus putting food on the table for that week, you can see what’s going to win.” (HP13, Community centre nurse, female)

“There’s been limitations in how they can access the treatment; often cost-related as well. And caught up in the fact that a lot of the patients with bad COPD often come from low socioeconomic backgrounds and they’re not working, there’s often huge financial strains on them.” (HP7, Respiratory physician, male)

Relationship between smoking, COPD and mental health

“It’s probably the other way around – chicken versus egg – usually their significant mental health problem precedes their COPD, and probably contributes to it because they smoke so much.” (HP15, Respiratory physician, female)

“It allays their anxiety – the continuing to smoke, and of course the continuing to smoke makes their lung disease worse and worse, so it’s a vicious circle.” (HP9, Respiratory physician, female)

“There’s a group of patients who are still smoking and that’s a really difficult thing to manage as well…. it prevents people from necessarily seeking treatment or engaging in treatment.” (HP7, Respiratory physician, male)