Introduction: Coal mining has been implicated as an environmental hazard with negative effects on community morbidity and mortality, although these findings have not been consistent To further explore these findings and adjust for potential confounding factors, county-level information on tons of underground, surface, and total coal mined, economic factors, and health factors and the relationship with mortality was examined. Purpose: The purpose of this analysis was to examine the association between diabetes mortality from 1962-2009 and cumulative coal production in Appalachian West Virginia, with and without control for covariates. Methods: Information on coal production, potential confounding variables, and mortality from 1962-2009 was collected for 31 Appalachian coal mining counties and 31 median-income matched non-coal mining counties. Negative binomial regression was used to estimate mortality rate ratios (RR) which included coal and statistically significant confounders. Results: Counties in the third and fourth quartiles of coal production had the highest rates of poverty, unemployment, obesity and smoking compared to the non-coal mining counties and counties with production in the first and second quartile. Base models found statistically significantly elevated RRs for diabetes mortality by quartile of coal production, adjustment for statistically significantly covariates attenuated the RRs Conclusion: The results of this study found evidence of higher diabetes mortality in coal mining counties in Appalachia, however these appear to be more highly associated with obesity, smoking, and poverty rates than coal production. Future studies should examine personal and environmental risks at the individual level.