Background <p>Primary care patients can benefit from counseling to address unhealthy lifestyle habits. Despite this, evaluations most often note that primary care facilities are not using the full potential of healthy lifestyle counseling methods. Studies comparing prevention efforts in different countries generally find substantial differences between countries. Quantitative studies carried out in a project targeting health professionals and patients in the U.S. and Sweden have demonstrated considerable differences between the two countries. In particular, U.S. health care professionals were found to be more engaged in lifestyle counseling than their Swedish counterparts. The aim of this qualitative study was to more fully explore and compare U.S. and Swedish primary care physician’s views on and involvement in promoting healthy lifestyles.</p> Methods <p>In total, 28 tape-recorded, semi-structured interviews were carried out with Swedish and U.S. primary care physicians. Data were analyzed using a combination of inductive and deductive qualitative content analysis approaches.</p> Results <p>Primary care physicians in both countries viewed addressing lifestyle habits like smoking, lack of physical activity and poor diet as important, but their level of commitment ranged “from dedicated to merely doing one’s duty”. This overarching theme was reflected across categories concerning role responsibility, client receptiveness and perceived impact, self-efficacy, supporting mechanisms, and working conditions. U.S. physicians were generally more engaged in promoting healthy lifestyles and described more structured routines and greater personal responsibility, whereas Swedish physicians more often relied on referral options and shared responsibility across professional groups. In both countries, lifestyle change was seen as difficult, and physicians’ involvement was shaped by confidence, skills, time, and available support. Limited resources and constrained working conditions, particularly lack of time, were barriers contributing to doubts about the effectiveness of counseling efforts.</p> Conclusions <p>There was consensus in both countries about addressing lifestyle habits as an integrated part of their role as primary care physicians. The study suggests that physicians were uncertain about the effectiveness of their interventions concerning unhealthy lifestyles, implying a need for further dissemination of the latest evidence for such interventions. Physicians requested a team approach for promoting healthy lifestyles with a clearly defined role for physicians in these efforts.</p>