 Of the nations 45 million adult smokers, nearly 20 million visit hospital emergency departments EDs each year. ED patients, particularly smokers, are disproportionately low-income, with limited access to traditional primary care settings. Patients presenting to the ED with a tobacco-related trigger event, like an asthma attack, may be experiencing a teachable moment. Thus, the ED may be an ideal location in which to identify smokers and initiate treatment for tobacco dependence. Initial pilot research by our group has demonstrated the feasibility of ED-based brief interventions for smokers. Based on our feasibility studies, the Institute of Medicine 2006 report on tobacco and the 2008 US Public Health Service guidelines now list EDs as appropriate loci for tobacco control efforts. This study aims to test the efficacy of an ED-initiated tobacco intervention which includes counseling and medication. The interventionScreening, Brief Intervention, and Referral to Treatment SBIRTuses a form of motivational interviewing known as the Brief Negotiation Interview BNI. Our proposed intervention combines a BNI with initiation of nicotine replacement therapy NRT and a fax referral to the state Smokers Quitline during the ED visit. A 6-week starter kit of NRT patch andor gum, tailored to level of addiction and patient preference will be provided with written materials. The initial dose of NRT will be given in the ED. A trained nurse will administer the booster intervention via telephone 3 days post-visit. The SBIRTNRT arm will be compared to standard care SC, which consists of written materials only, in a controlled trial of 778 smokers age 18 years or older randomized in a 1:1 fashion. 