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Previous research has documented that hospital-based smoking-cessation counseling is efficacious and cost-effective when delivered by research staff. This study evaluated the implementation and effectiveness of this intervention program when delivered by respiratory therapists chosen from the regular hospital staff.A total of 1,173 hospitalized smokers were randomly assigned to either usual care or a stage-based bedside counseling program supplemented with a videotape, self-help materials, and a follow-up telephone call.Using an intent-to-treat analysis and counting those lost to follow-up as smokers, we did not find a significant difference in outcome between intervention (14.2% reported being abstinent for ≥6 months at the 1-year follow-up) and usual care conditions (13.6% abstinence). Process analyses revealed that these results were due to a combination of failure to reach many patients and reduced effectiveness of respiratory therapist interventionists compared with experienced professional counselors in a previous study conducted in the same hospitals.We recommend implementation of hospital-based smoking-cessation counseling by professional counselors whose primary responsibility is to deliver the intervention. Recommendations for future research and for innovative ways to reach hospitalized smokers who are not receiving intervention are discussed.