Background: In 2000, the American College of Obstetricians/Gynecologists (ACOG) established the 5 A's method of brief smoking cessation counseling (ask, advise, assess, assist, arrange) as a standard component of prenatal care. The purpose of this study was to describe use of the 5 A's in prenatal care in Northeast Tennessee, where pregnancy smoking rates are three times the national average, and to evaluate provider attitudes toward addressing pregnancy smoking. Method: Surveys were distributed to all obstetric practices in a 6-county area. Results: One-quarter of respondents indicated they always asked pregnant patients about smoking, with two-thirds always giving their pregnant smokers advice to quit. Over half reported always assessing willingness to quit, while one-quarter or fewer always provided quit assistance, or arranged follow up. Over half believed addressing smoking was of significant value. Secondhand smoke was infrequently addressed. Demographics, efficacy, and outcome beliefs predicted use of the 5 A's. Conclusions: Most obstetric providers in Northeast Tennessee are not following ACOG recommendations for pregnancy smoking. Efforts to address pregnancy smoking and associated adverse pregnancy outcomes in the region should include facilitation of smoking cessation interventions in prenatal care.