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The Appalachian Region has among the highest rates of smoking and smoking-related illness in the United States. Strong smoke-free legislation could help protect nonsmoking residents from the harmful effects of secondhand smoke. However, there is a dearth of state, county, city, and subcounty smoke-free law coverage throughout Appalachia. As of July 2016, only 21% of Appalachian residents were covered by comprehensive smoke-free laws (i.e., 100% coverage for workplaces, restaurants, and bars). Only 46% of Appalachians lived in places with 100% smoke-free workplace laws, only 30% lived in places with 100% smoke-free restaurant laws, and only 29% lived in places with 100% smoke-free bar laws. Reasons for this lack of smoke-free law coverage include socioeconomic disadvantage, the historical importance of tobacco in Appalachian economies, and preemptive state legislation. By understanding the contextual issues that have inhibited smoke-free legislation, smoke-free advocates will be better prepared to lead efforts that expand smoke-free coverage in this region.