Smoking is the leading cause of preventable death worldwide and remains a critical public health challenge. The burden of disease caused by smoking is disproportionately borne by persons living with mental illness. Public health efforts to address smoking have not historically translated to a significant reduction in smoking prevalence among patients with mental illness. Smoking is a substantial cause of morbidity and mortality among psychiatric patients who smoke at 1.7 to 3.3 times the rate of the general population. Among those with serious mental illness, tobacco-related illness accounts for half of all deaths. Nicotine dependence also interferes with treatment and worsens many psychiatric symptoms. Interventions are underutilized due to persistent misunderstandings regarding tobacco cessation for patients who are mentally ill. Addressing these misunderstandings is crucial in targeting the disparate rates of smoking in this population. Therefore, it is incumbent on psychiatrists to address the outsized effect that smoking has on patients with mental illness.