Background <p>Although pregnancy represents a critical window for implementing behavioral health interventions, tobacco use and secondhand smoke exposure among pregnant women remain understudied in Saudi Arabia.</p> Objectives <p>This study aimed to determine the prevalence of tobacco use and secondhand smoke (SHS) exposure during pregnancy in Al-Madinah city, Saudi Arabia. It also sought to assess women’s knowledge and attitudes regarding the health risks of tobacco use and SHS, examine household smoking practices, and evaluate the extent of healthcare providers screening for tobacco use during pregnancy.</p> Methods <p>A cross-sectional study was carried out in Al-Madinah, Saudi Arabia, between October and December 2024 in which a self-administered questionnaire was distributed to women in the postnatal ward. The data collected were related to tobacco use, SHS exposure, knowledge and attitudes toward tobacco risks, household smoking policies, and whether healthcare providers had inquired about tobacco use in the past year.</p> Results <p>A total of 469 women participated in the study, with a mean age of 31.8 years (SD = 5.8). The prevalence of active smoking was 3.3% for combustible tobacco, while it was 0.9% for e-cigarettes, and 28.3% for SHS exposure. Women of age ≤ 25 years accounted for 75% of current e-cigarette users (<i>p</i> = 0.028). Similarly, the smoking status of husbands was associated with SHS exposure (<i>p</i> &lt; 0.001). While 51.6% of respondents acknowledged that SHS poses serious health risks, only 9.2% reported being screened for tobacco use by a healthcare provider.</p> Conclusions <p>Although active smoking during pregnancy is low, SHS exposure remains prevalent and inadequately addressed. These findings underscore the need for routine screening by healthcare providers and targeted family-based interventions in maternal health programs.</p>