Brief alcohol counseling from a medical provider can benefit patients with alcohol misuse. However, most providers do not offer such counseling. This study audiotaped primary care appointments of patients with alcohol misuse and sought to understand barriers to brief alcohol counseling. Three themes emerged from qualitative analyses. First, patients disclosed information regarding their drinking, but providers often failed to explore these offerings. Second, alcohol counseling was usually vague and tentative, whereas advice about smoking was more clear and firm. Third, providers appeared uncomfortable during most alcohol-related discussions. Findings suggest that provider discomfort and avoidance are important barriers to alcohol counseling.