Background: In Alabama, lung cancer is the leading cause of cancer death. High lung cancer incidence and mortality rates are attributed to high smoking rates among underserved, low-income, and rural populations. Residents in rural Alabama tend to be older, engage in risky health behaviors, and have lower adherence to preventive care than their urban and suburban counterparts. Disparities in mortality rates between rural and urban areas are substantial for lung cancer. It can be explained by increased tobacco use and the preponderance of late-stage diagnoses following the lack of uptake of lung cancer screening (LCS). Therefore, we examined factors associated with LCS uptake among patients referred for screening at the University of Alabama at Birmingham (UAB). Methods: A retrospective cohort of patients at UAB who were eligible for lung cancer screening between 01/01/2015 and 12/31/2020 was used to define the cohort. Eligibility was defined as individuals between 55-80 years old, without diagnostic codes for lung cancer (ICD-9 162.9 or ICD-10 C34.90 within the past ten years), and had a smoking history. Patient demographic variables included Age, Sex, Race/Ethnicity, RUCA codes, and distance from UAB. Chi-square tests and Student t-tests were used to compare screening uptake across patient demographic and clinical variables. Bivariate analyses were used to determine significant predictors of lung cancer screening uptake at UAB. Results: Of the 67,355 identified as eligible for LCS, only 1147 (0.017%)were screened. Sixteen individuals were not AL residents and therefore were not included in further analysis. Of those 1129 individuals screened, the mean age was 67.02, male (54.92%) and Non-Hispanic White (57.77%). Compared to those not screened (97.86%), those screened (2.14%) were more likely to live in an urbanized area. Additionally, compared to those not screened (50.52 mi), those screened were more likely to live closer to UAB (22.06 mi). Conclusions: Findings show a substantial disparity between adults living in rural areas and those living in more urbanized areas regarding LCS use. Furthermore, the study provides evidence that LCS has not reached all subgroups and that additional targeted efforts are needed to increase lung cancer screening uptake.