Smoking is North America's leading cause of preventable morbidity and mortality. Although effective cessation treatments exist, their overall effect is modest, and they rarely reach the high-risk, health-compromised smokers who need them most. Surprisingly, despite evidence that marital relationship variables predict the success of cessation efforts, family systems ideas have had little impact on current intervention research. We review and critique the cessation literature from a systemic viewpoint, illustrate two couple-interaction patterns relevant to the maintenance of high-risk smoking, and outline a family-consultation (FAMCON) intervention for couples in which at least one partner continues to smoke despite having heart or lung disease. Taking into account ironic processes and symptom-system fit, FAMCON focuses on the immediate social context of smoking, aiming to interrupt well-intentioned "solutions" that ironically feed back to keep smoking going, and to help clients realign important relationships in ways not organized around tobacco usage. Currently in its pilot-testing phase, FAMCON is an adjunctive, complementary approach designed to include collaboration with primary-care physicians and to make smokers more amenable to other, evidence-based cessation strategies.