OBJECTIVE: The first obstetric visit is an opportunity to provide counseling to women with substance abuse risks, including smoking, drug use, and alcohol use. Little is known about how obstetric care providers and patients discuss these issues. Our objective was to examine patient-provider communication about substance use behaviors during these visits. METHODS: We audio-taped and transcribed verbatim first prenatal visits in an outpatient hospital clinic, then qualitatively analyzed them for content and process of communication using modified grounded theory methods. RESULTS: Twenty-nine providers (21 residents, 5 midwives, 3 nurse practitioners) and 51 patients participated. Twenty-five patients were smokers, 4 used alcohol, and 11 used drugs. Provider responses to smoking disclosures included discussions of risks, encouragement to quit-cut down, affirmation of attempts to quit-cut down, and referral to smoking cessation programs. Responses to alcohol or drug disclosures included only a general statement regarding risks and referral to genetics. CONCLUSION: Providers were less attentive to alcohol and drugs than smoking where they had pre-established patterns of response. PRACTICE IMPLICATIONS: Providers should discuss behavioral change strategies and motivations with pregnant patients who use drugs and/or alcohol as well as those who smoke.