Appalachia has higher morbidity and mortality compared to the nation, and suffers greater socioeconomic disadvantages. This article investigates the relationship of coal mining to elevated mortality rates in Ap-palachia. Total mortality rates for the years 1999–2004 were investigated in a national county-level anal-ysis that included coal mining as the primary independent variable. Counties in Appalachia where coal mining is heaviest had significantly higher age-adjusted mortality compared to other Appalachian coun-ties and to other areas of the country. Elevated mortality rates persisted in Appalachian coal mining ar-eas after further statistical adjustment for smoking, poverty, education, rural-urban setting, race/ethnic-ity, and other variables. After adjustment for all covariates, Appalachian coal mining areas were characterized by 1,607 excess annual deaths over the period 1999–2004. Adjusted mortality rates increase with increasing coal production from 1 to 7 million tons. These findings highlight environmental inequities that persist in Appalachian coal mining areas. Reducing these inequities will require development of al-ternative economies and promotion of environmental justice through regulatory and allocative policy changes.