Purpose: In a 2016 report, nearly 2500 Nebraskans registered for Nebraska Tobacco Quitline (NTQ) but only 53% of participants indicated they found out about the quitline from their provider. A critical need exists to improve tobacco quitline use by clinical staff and settings to increase tobacco cessation and reduce tobacco-related morbidity and mortality. The purpose of this study was to obtain information by surveys on the use of NTQ by Federally Qualified Health Center (FQHC) clinical staff and settings. Authors hypothesized that there are factors that explain the underutilization of NTQ. Specific aims were to 1) identify FQHC clinical staff and setting characteristics that influence current tobacco cessation assessment and interventions, and 2) identify barriers and facilitators that influence future use of NTQ by FQHC clinical staff and settings. Methods: This mixed methods study recruited from all seven Nebraska FQHC settings. All FQHC provider and non-provider clinical staff were invited to complete a Clinical Staff Survey. The Medical Director, Associate Medical Director, or Nurse Manager at each FQHC was a proxy for the setting and eligible to complete the Setting Survey. After survey data collection, clinical staff were invited to a follow-up interview to better understand identified barriers and facilitators to future use of NTQ. Descriptive statistics were used to report percentages and qualitative data were analyzed using pattern coding. Results: The main findings include the limited role for non-providers in tobacco cessation efforts beyond assessment, the lack of supportive setting processes for intervention use, and insufficient awareness and perceived effectiveness of NTQ. Providers reported using tobacco cessation interventions more frequently than non-providers. Electronic Health Record (EHR) processes that impede NTQ included the lack of prompts by the EHR to document a patient-directed tobacco cessation goal and interventions, and lack of EHR facilitation for recommending interventions. Processes beyond the EHR included lack of time. Clinical staff reported insufficient awareness and perceived effectiveness of NTQ as compared to pharmacological interventions. Conclusions: This study supports role expansion for non-providers, adding EHR prompts and e-referral capability to increase NTQ referral and use, and targeted efforts to increase awareness and improve perceived effectiveness of NTQ.