Objective: Effective preconception primary prevention strategies are needed for women who are at dual risk for alcohol and smoking exposed pregnancies. The current study seeks to identify risk factors that can be used to target intervention strategies at women who are at dual risk. Methods: During a 2-year period from January 2007 through December 2009, 109 women at dual risk for alcohol exposed pregnancy (AEP) and smoking exposed pregnancy (SEP) and 108 women at risk only for AEP were recruited from central Virginia cities. All participants completed a battery of instruments, including assessments of sexual, smoking, and alcohol history and current behavior in each area. Results: Several factors differentiated women at dual risk for SEP/AEP vs. AEP alone, including lower educational level and employment, higher frequency of sexual intercourse, less use of contraception, and higher frequency of alcohol use and mental disorders. Conclusions: Several measurable factors differentiate SEP/AEP women, and these factors could be used to efficiently target primary prevention. The increased severity of women at dual risk of SEP/AEP on a variety of factors demonstrates the importance of preconception prevention efforts for these women. © Copyright 2011, Mary Ann Liebert, Inc.