Context: Disparities in the availability of nutritionally important foods and their influence on health have been studied in US urban communities. Purpose: To assess the availability of selected retail foods and cigarettes, and explore ecologic relationships of the availability with obesity and smoking in rural communities. Methods: Inventories of all food stores (n = 182) in 2 rural New York counties were surveyed. The study area was divided into 4 regions through cluster analysis of 2000 Census and geographic information system data. Weight-adjusted per 10,000-population density of stores carrying selected foods was used as a standardized measure of availability. Prevalence of overweight/obesity (BMI greater than or equal to 25.0 kg/m[superscript 2]) and smoking among adults was obtained from secondary data. Bivariate correlations among availability of foods and cigarettes, overweight/obesity, and smoking were analyzed at the regional level. Findings: Nutritionally important foods, including fresh fruit, vegetables (dark green or orange colored), low-fat (less than or equal to 1%) milk, high-fiber (greater than or equal to 2g per slice) bread, and fish were most available in the semiurbanized region, followed by the rural heartland, the remote mountains region, and the most urbanized inner-town. No significant difference was found in the availability of general food items and cigarettes. Overweight/obesity was inversely associated with the availability of fresh fruit, vegetables, and low-fat milk. Smoking was positively associated with the availability of cigarettes, white bread, whole milk, and eggs. Conclusions: The observed disparities in food availability and their ecologic association with health risks in rural adults expanded the knowledge base of built environment and its association with health beyond the urban setting.