BACKGROUND AND OBJECTIVE: Although comprehensive smoking counseling to limit secondhand smoke (SHS) is widely endorsed, it is often not done. Published evaluations of brief and practical systems that improve screening and counseling to reduce SHS are limited. Our objective was to determine if a quality improvement activity around smoking counseling leads to changes in (1) medical assistant and pediatric provider assessment of smoking history and (2) smoking or other behaviors affecting children' s SHS exposure. METHODS:In a large urban teaching clinic we assessed the ONE Step intervention, which included the following: (1) "Ask" (medical assistant asking whether caregivers smoke); (2) "Advise" (providers advising smoking outside and quitting if ready); (3) "Refer" (providers referring to the Colorado telephone QuitLine); and (4) electronic medical record prompts and required documentation regarding smoking. Medical assistant and provider assessments of smoking were evaluated with a chart review by using a pre-/posttest design. Caregiver behavior change was evaluated with a time-series survey that included assessment at baseline and follow-up via telephone at 6 and 12 months from study entry. RESULTS: ONEStep was associated with a statistically significant increase in Ask, Advise, and Refer documentation. Caregiver surveys showed that 97% found discussions of SHS with providers acceptable. Six-and 12-month follow-ups, respectively, showed that 14% and 13% of smokers reported quitting and that 63% and 70% of current smokers reported reduced SHS exposure. CONCLUSIONS: ONEStep was feasible to deliver in a busy outpatient setting, acceptable to families, and appears to have resulted in decreased exposure to SHS in our pediatric population. Pediatrics 2013;132:e502-e511 AUTHORS: