The objective of this study was to examine Ohio nurse-midwives' perceptions and use of a smoking cessation protocol in assisting pregnant smokers. The total population of licensed Ohio nurse-midwives (n = 300) was surveyed by using a cross-sectional survey design. Only 4 of 10 items that assessed a nationally recommended method of promoting smoking cessation were done by 50% or more of respondents. Few nurse-midwives identified barriers to counseling pregnant patients who smoked, but the most common were lack of time (14%) and not knowing where to send pregnant smokers for treatment (14%). Most respondents believed that nicotine replacement therapy (NRT) would be most likely to reduce the number of pregnant smokers (74%), yet few (26%) were confident in their ability to prescribe/recommend nicotine replacement therapy. Respondents more likely to use 5 A's can be characterized as the following: had higher efficacy expectations in their ability to communicate issues about the 5 A's and had higher outcome expectations regarding the effects of using the 5 A's. Nurse-midwife training programs and continuing education needs to include current research in nicotine replacement therapy use in pregnant patients and 5 A's techniques to assist pregnant smokers in quitting.