In Appalachian areas, strong tobacco control policies are not in place, so residents are not adequately protected from secondhand smoke exposure. This area is predominantly rural, and residents experience a high burden of tobacco-related illnesses. There has been limited examination of elements that hinder smoke-free policy adoption in these vulnerable communities. Key informant interviews were conducted with individuals identified as being knowledgeable about local tobacco control policy activities within a random selection of Appalachian communities within 6 states with (n = 15) and without (n = 12) local smoke-free policies. Five key themes emerged from the qualitative interviews: (1) opposition to tobacco control, (2) need for local involvement, (3) role of community coalitions, (4) leveraging outside advocates, and (5) working with decision makers. In Appalachian communities, the local context and locally-based coalitions were critical to promote the adoption of smoke-free policies.