Objectives Despite a decline in cigarette smoking in the United States, high rates persist among the socioeconomically underserved who consequently are at risk for smoking-related disease (SRD). Since academically affiliated dental clinics are more likely to encounter underserved patients, smoking interventions could address both the oral and systemic risks of continued smoking. To determine the relevance of providing smoking counseling in the context of SRD, this study examined the prevalence of smoking and its associations with socioeconomic status (SES), SRD and its sequela, and medication use. Methods Socioeconomic and smoking status was determined from 1,797 electronic health records of a sample of patients at a Pennsylvania dental clinic in 2010. Low SES included patients who were covered by a Medicaid program (MA) or “self-payers.” High SES encompassed those with an employment-based commercial dental insurance (COM). Self-reported smoking rates were compared with patients’ SES, SRDs or sequela, and medications being used for the management of their SRDs. Results Overall, 41.7 percent of these patients were smoking. Smoking was related to SES with the highest rate (52.7 percent) among MA patients compared with 31.5 percent in patients with COM. In addition, 37 percent of patients with SRD or sequela and 33 percent who were taking medications for their management were smoking. Conclusions Academically affiliated dental clinics are more likely to encounter underserved patients who smoke and have SRD. For greater patient impact and receptivity, it is essential that tobacco cessation interventions emphasize the risks of smoking on systemic as well as oral health.