Patients who smoke represent a frustrating social paradox. The harmful effects of tobacco use have been well publicized in the past 50 years, yet more than one in five adults in the United States continue to smoke. A better understanding of the nature of nicotine addiction, of behavioral learning, and of common misconceptions regarding tobacco use treatment, can create new opportunities to impact smoking by offering clinicians novel methods of influence that have otherwise not be available within the traditional cessation approach. Understanding and dealing with the paradox can provide more productive and meaningful ways of improving not only health, but potentially also improving well-being.