Tobacco smoking perpetuates the disadvantages experienced by Aboriginal and Torres Strait Islander people in Australia. Tobacco smoking is a risk factor for poor maternal and infant outcomes in pregnancy. Over half of Aboriginal and Torres Strait Islander women smoke during pregnancy and few successfully quit. Aboriginal and Torres Strait Islander women face many intrinsic barriers to quitting such as low socioeconomic disadvantage and patterns of use in family networks. There are also several extrinsic hurdles surrounding current practice guidelines and policy that may limit success in reducing smoking rates among Aboriginal and Torres Strait Islander women during pregnancy: the use of the Stages of Change (SOC) model; delay in the use of nicotine replacement therapy (NRT); and the absence of subsidised intermittent NRT. A more proactive approach towards smoking cessation for pregnant Aboriginal and Torres Strait Islander women may be necessary, including moving away from the SOC model approach and subsidised provision of intermittent NRT. Comprehensive programs that take into account the family network and wider social context are also recommended.