CONTEXT: Despite a decision by the Food and Drug Administration to deny over-the-counter status to emergency contraceptive pills, pharmacists play a critical role in a woman's access to this medication, especially in areas with large rural populations. Pharmacists' knowledge about and attitudes toward emergency contraceptive pills may affect whether pharmacies carry the medication and whether individual pharmacists dispense it. METHODS: In October 2003, all registered pharmacists living and working in South Dakota were mailed a survey to assess their dispensing practices for, knowledge about and attitudes toward emergency contraceptive pills. Data for 501 respondents were analyzed through chi-square testing and multivariate logistic regression. RESULTS: Fifty-four percent of respondents worked in pharmacies that carried emergency contraceptive pills. Of these, 67% had dispensed the medication in 2003, and 24% were not comfortable providing customer counseling about the method. Thirty-seven percent of all pharmacists did not understand its mechanism of action; 43% and 21%, respectively, incorrectly answered questions about the medication's link to birth defects and health risks. Only 5% correctly answered all three questions. Eighty-four percent of surveyed pharmacists believed that the medication should not be made available over the counter. Multivariate analysis showed that knowledge of emergency contraception and support for over-the-counter status were relatively low among pharmacists working in small communities. CONCLUSIONS: The education of pharmacists about emergency contraceptive pills must be strengthened to ensure that women receive accurate medical information and access to all contraceptive services.