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Background: The U.S. Department of Health and Human Services’ initiative Healthy People 2020 targets tobacco use, including smoking during pregnancy, as a continuing major health concern in this country. Yet bringing the U.S. Public Health Service's 2008 clinical practice guideline, Treating Tobacco Use and Dependence, into routine prenatal care remains challenging. Our previous nurse-managed intervention study of rural pregnant women found no significant cessation effect and significant discordance between self-reported smoker status and urinary cotinine levels.Purpose: The overall purpose of this follow-up study was to increase our understanding of the experiences of pregnant smokers and their providers. No qualitative studies could be found that simultaneously explored the experiences of both groups.Design and methods: This qualitative descriptive study used focus group methodology. Nine focus groups were held in two counties in upper New York State; six groups consisted of providers and three consisted of pregnant women. Four semistructured questions guided the group discussions, which were audiotaped and transcribed verbatim. Transcripts were read and coded independently by six investigators. Themes were identified using constant comparative analysis and were validated using the consensus process.Results: The total sample consisted of 66 participants: 45 providers and 21 pregnant women. Most of the providers were white (93%) and female (93%). A majority worked as RNs (71%); the sample included perinatal and neonatal nursery nurses, midwives, and physicians. The pregnant women were exclusively white (reflecting the rural demographic); the average age was 24 years. All the pregnant women had smoked at the beginning of their pregnancies. Four common themes emerged in both the provider and the pregnant women groups: barriers to quitting, mixed messages, approaches and attitudes, and program modalities. These themes corroborate previous findings that cigarette smoking is used for stress relief, especially when pregnancy itself is a stressor, and that pregnant women may feel guilty but don't want to be nagged or preached to.Conclusions: These results have implications for how smoking cessation programs for pregnant women should be designed. Health care providers need to be cognizant of their approaches and attitudes when addressing the subject of smoking cessation. Specific educational suggestions include “putting a face” to the issue of tobacco use during pregnancy. More research is needed on how best to implement the 2008 clinical practice guideline in specific populations.