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Lung cancer, the second most commonly diagnosed cancer, is a leading cause of death among older adults (Cronin et al., 2018; Siegel, Miller, & Jemal, 2017). While there are numerous health benefits associated with smoking cessation in patients with advanced lung cancer (Gemine & Lewis, 2017; Parsons, Daley, Begh, & Aveyard, 2010), conversations about smoking cessation are infrequent and often lack physician support for cessation (Warren, Marshall, et al., 2013; Wells et al., 2017). Physicians may avoid lengthy conversations about smoking to protect patients from feeling shame and guilt due to the perceived stigma associated with smoking and a lung cancer diagnosis (Champassak et al., 2014; Wells et al., 2017). However, given that conversations about smoking increase patients’ success rates with smoking cessation (Stead, Bergson, & Lancaster, 2013), it is important to examine how physicians can tailor conversations about smoking to patients with lung cancer taking stigma into consideration. Thus, the primary aim of this study was to examine the current state of conversations about smoking with patients with lung cancer, for the purpose of providing an account of the communication behaviors that are present, and suggestions for communication behaviors that may be lacking. To examine how physicians navigate conversations about smoking with patients with lung cancer, qualitative content analysis was performed on 58 transcripts of conversations recorded during an initial appointment with a standardized patient. We found that a majority of physicians initiated conversations about smoking, often during the medical history charting process or during conversations about the lung cancer diagnosis. The content of conversations about smoking generally fit within six categories: assesses smoking status, builds smoking history profile, praises smoking cessation, connects smoking behaviors to diagnosis or treatment, provides empathy or understanding, and presents a negative bias about smoking. Finally, approximately one-third of physicians provided emotional support for smoking cessation or smoking-related stigma. Findings indicate that while a majority of physicians ask patients about smoking, most physicians aimed for these conversations to be short, routine, and medically driven. Therefore, conversations about smoking were not tailored to meet the specific needs of patients with lung cancer, which might include additional provision of support for smoking cessation and recognition of smoking-related stigma.