Physician and CEO, Chicago Allergy Center, and board director at American Lung Association

Juanita Mora, MD

ALA State of the Air 2026: Clinician Action

The American Lung Association (ALA)'s 2026 State of the Air report documents a continued and in some measures worsening picture of air quality across the United States. The 27th edition of the annual assessment finds that 44% of Americans — 152.3 million people — live in counties that received failing grades for unhealthy ozone or fine particulate matter (PM2.5) levels, with nearly 4 million more people breathing unhealthy ozone compared with the prior year's report.¹ Failing ozone grades now cover 219 counties across 36 states, the broadest distribution since 2016.¹ The report attributes the trend in part to the compounding influence of climate change on ozone formation conditions, as well as to wildfire smoke events with expanding geographic footprints.¹

Children represent both the most exposed and the most physiologically vulnerable population in these findings. Some 33.5 million children — 46% of those under 18 — live in counties that failed at least one air quality measure, and 7.3 million live in communities failing all 3.¹ Developing lungs are uniquely susceptible to the effects of chronic pollution: children breathe proportionally more air for their body size than adults, spend more time outdoors, and face cumulative developmental consequences from exposure during periods of active lung growth. Hispanic and Latino children bear a disproportionate share of this burden, with the report finding they are approximately 3 times more likely than white children to live in a community that fails all three pollutant grades.¹ Bakersfield, California — which carries both chronic ozone and particle pollution burdens — ranked as the metropolitan area with the worst year-round particle pollution for the seventh consecutive year.¹

 spoke with Juanita Mora, MD, allergist-immunologist at Chicago Allergy Center and attending physician at Advocate Illinois Masonic Medical Center, and Vin Gupta, MD, MPA, pulmonologist and Managing Director of Health Innovation at Manatt, also of Virginia Mason Medical Center and MS NOW news, about what the 2026 findings mean for patients and for the field. Mora, a medical expert for the ALA, focused on the clinical stakes for children with developing lungs and called on clinicians to engage legislators on maintaining EPA funding and clean air protections. Gupta, an ALA board member, framed the report's value primarily as a public education opportunity, while expressing skepticism that the current administration's regulatory posture will shift in response to it — and arguing that the more effective path forward lies in communicating about air quality in non-divisive, fact-centered terms capable of reaching a broader public over time.

“How do we smartly animate people? I think a lot less of it is stoking division and creating conflict, and it's more about persuasion through just informing… I do think there's a majority of this country, when given facts in a calm, rational, apolitical way, will be able to at least receive that message,” Gupta said.

The full 2026 State of the Air report is available at lung.org/SOTA.

American Lung Association. State of the Air 2026. Published April 21, 2026. 

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Drs. Vin Gupta and Juanita Mora discuss the recent report and how it should inform clinician actions.

ALA State of the Air: Nearly Half of American Children Breathe Poor Air

Nearly half of all children in the United States — 33.5 million, or 46% of those under 18 — live in counties that received a failing grade for at least one measure of air pollution in the 

 (ALA)'s 27th annual State of the Air 2026 report, which evaluates 3 years of EPA-verified monitoring data (2022–2024) across ozone, short-term particle pollution, and long-term particle pollution. Overall, 152.3 million Americans — 44% of the population — live in communities earning a failing grade for at least one pollutant. 

Juanita Mora, MD, an allergist-immunologist at Chicago Allergy Center and attending physician at Advocate Illinois Masonic Medical Center in Chicago, Illinois, and board director of the ALA, described the findings as both a public health indictment and a call to clinical action.

The report grades counties on 3 measures: ground-level ozone (smog), short-term particle pollution spikes, and long-term average particle pollution. Ozone forms when vehicle exhaust, industrial emissions, and chemical compounds react with sunlight; the report found that approximately 4 million more people are now breathing unhealthy ozone levels compared with last year's report — a worsening trend driven in part by warming temperatures that enhance ozone formation. 

Nearly 33 million people live in counties earning failing grades across all 3 measures. Bakersfield, California, ranked as the metropolitan area with the worst year-round particle pollution for the 7th consecutive year; Los Angeles retained its position as the most ozone-polluted city in the nation, a ranking it has held in 26 of the report's 27 years.

Mora described the health consequences of both pollutant categories in clinical terms she communicates directly to patients and families. Ozone causes acute airway inflammation triggering wheezing and cough in children and exacerbating asthma and COPD. Long-term exposure to fine particulate matter has systemic reach that extends well beyond the lung: particles enter the bloodstream and have been associated in the epidemiologic literature with increased cardiovascular risk including heart attack and stroke, dementia and Alzheimer's disease with repeated cerebrovascular exposure, and, in pregnant women, elevated risk of preterm delivery. 

The ALA report frames wildfire smoke as a growing contributor to both ozone and particle pollution burden, with wildfire events in Canada, California, and the eastern United States increasingly affected air quality across broad geographic regions and populations not historically considered at elevated pollution-related risk.

Racial and socioeconomic disparities in air pollution exposure are a central feature of the 2026 report's findings and a theme Mora returned to throughout her comments. According to the report, a person of color is more than 2.4 times as likely as a white individual to live in a community with failing grades across all 3 pollution measures, and Hispanic individuals are more than 3 times as likely. Communities in Texas, California, and across the South carry disproportionate combined ozone and particle pollution burdens. 

Mora called on clinicians to use the report's county-level data — available at 

 — as a tool for contextualizing patient respiratory symptoms and for counseling families about modifiable risk, including indoor air quality, secondhand smoke exposure, and activity timing on high-pollution days. On the policy dimension, Mora expressed concern that current EPA regulatory rollbacks — including changes to economic analyses used to set pollution standards — threaten to undermine the Clean Air Act's multi-decade legacy of reducing air pollution–attributable mortality and morbidity. Children, with developing lungs, are the most biologically vulnerable to the long-term consequences of chronic pollution exposure and continued investment in EPA enforcement and ambient air quality standards are a pediatric health imperative.

“These kids do not have clean air to breathe. Let's do more. We can do more to clean air up,” Mora said. “… Let’s teach our families to keep safe and talk to our legislators about keeping the EPA environmental protection agency funding as is so that way we can continue to make these kids healthy adults.”

Editor’s note: Mora has no relevant disclosures to report.

American Lung Association. State of the Air 2026. 27th ed. Published April 21, 2026. Accessed May 7, 2026. 

Juanita Mora, MD, discusses The American Lung Association's 2026 report, elucidating a disproportionate burden on people of color.

Novel Therapies, New Guidelines Reshape Asthma Management, With Juanita Mora, MD

 treatment landscape has been fundamentally transformed by the expansion of biologic therapy options, and the decisions clinicians now face in selecting among them have grown considerably more nuanced — a challenge Juanita Mora, MD, an allergist-immunologist at Chicago Allergy Center and attending physician at Advocate Illinois Masonic Medical Center in Chicago, Illinois, frames as a welcome one in a conversation with 

Six FDA-approved biologics are currently available for severe asthma — omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab — with the December 2025 approval of depemokimab (Exdensur, GSK) adding a seventh. Each agent targets a distinct point in the type 2 inflammatory cascade: omalizumab blocks IgE; mepolizumab, reslizumab, and benralizumab target the IL-5 pathway; dupilumab inhibits IL-4 and IL-13 signaling via the IL-4 receptor α chain; and tezepelumab blocks thymic stromal lymphopoietin (TSLP), an upstream alarmin with the broadest applicability across asthma phenotypes. Real-world utilization has shifted markedly in recent years toward dupilumab and tezepelumab, reflecting their broader phenotypic applicability and the growing recognition that TSLP blockade can benefit patients irrespective of eosinophil levels.

Without head-to-head comparative trial data — a persistent gap in the evidence base — Mora relies on a phenotyping-first framework when selecting among agents. Skin testing and specific IgE panels inform identification of allergic asthma phenotypes, where omalizumab remains the established option. Blood eosinophil counts guide selection among anti-IL-5 pathway and anti-TSLP agents. She highlighted the clinical utility of matching biologic choice to coexisting comorbidities: dupilumab, mepolizumab, and omalizumab all carry FDA approval for chronic rhinosinusitis with nasal polyps in addition to asthma, making them preferable single-agent options for patients with that common comorbidity, and dupilumab additionally covers eosinophilic esophagitis — a consideration that often arises in her patient population.

Depemokimab represents a conceptual addition to the severe asthma biologic toolkit beyond just its mechanism. As the first and only biologic for asthma approved with a twice-yearly dosing schedule, it is the first anti-IL-5 antibody engineered with an extended half-life to enable semi-annual administration rather than the every-4-week or every-8-week regimens used by existing agents in the class. In the phase 3 SWIFT-1 and SWIFT-2 trials, depemokimab reduced the annualized asthma exacerbation rate by 58% (rate ratio, 0.42; 95% CI, 0.30–0.59; 

 <.001) and 48% (rate ratio, 0.52; 95% CI, 0.36–0.73; 

 <.001), respectively, versus placebo in patients with severe eosinophilic asthma on standard of care. Mora emphasized the access and adherence implications of twice-yearly dosing in particular: for patients with limited transportation, inflexible work schedules, or infrequent health system contact, reducing the injection burden to 2 visits per year may be the practical difference between consistent biologic exposure and treatment dropout.

On inhaler-based management, Mora noted that the field has also undergone a meaningful shift at the step-down end of the treatment spectrum with the broad adoption of SMART (Single Maintenance and Reliever Therapy). Updated Global Initiative for Asthma (GINA) guidelines now recommend against short-acting β₂-agonist (SABA) monotherapy as rescue in asthma, favoring instead a combination inhaled corticosteroid/formoterol regimen that addresses both bronchoconstriction and the underlying airway inflammation driving the acute episode. 

“I think the more comfortable we get with this new rescue therapy, using SMART therapy as rescue, we will have a lot more transitioning of our primary care doctors also writing it and getting more patients under better control,” Mora said.

Mora has no relevant disclosures to report.

Jackson DJ, Busby J, Pfeffer PE, et al. Twice-yearly depemokimab in severe asthma with an eosinophilic phenotype. 

. 2024;391:2337-2349. doi:10.1056/NEJMoa2406673

GlaxoSmithKline. FDA approves Exdensur (depemokimab-ulaa) for the treatment of severe asthma with an eosinophilic phenotype. Press release. December 16, 2025. 

https://www.gsk.com/en-gb/media/press-releases/exdensur-depemokimab-approved-by-us-fda-for-the-treatment-of-severe-asthma/

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2025 update. 

 The severe asthma treatment landscape has entered a period of rapid evolution — with patient access and adherence increasingly driving clinical decisions.

World Asthma Day 2026: Uncontrolled Disease and Racial Disparities Demand Structural Solutions, With Juanita Mora, MD

 affects an estimated 27 to 30 million Americans — with a substantial proportion remaining inadequately controlled despite available therapies — World Asthma Day 2026 offers an opportunity to reckon with the structural and systemic forces that are keeping effective treatment out of reach for the patients who need it most, according to Juanita Mora, MD.

Mora, an allergist-immunologist at Chicago Allergy Center and attending physician at Advocate Illinois Masonic Medical Center in Chicago, Illinois, emphasized that uncontrolled asthma in the United States is not primarily a treatment gap but an access and equity gap. The most striking illustration of that inequity is the racial disparity in asthma mortality: according to federal surveillance data, Black American adults are more than twice as likely to die from asthma compared with US adults overall, and Black American children are approximately 3 to 4 times more likely to die from asthma than their white peers — disparities that persist despite decades of therapeutic advances and that Mora characterized as preventable.

She identified several overlapping structural barriers driving these outcomes. Lack of health insurance remains a fundamental obstacle, leaving many patients without reliable access to prescription medications and specialist care. The cost of asthma medications — including both daily controller inhalers and biologic therapies for severe disease — is a second distinct barrier, one Mora noted she has been actively engaged in addressing through advocacy efforts. Geographic access to specialists is a third constraint: patients in many communities must travel 30 or more miles to reach an allergist or pulmonologist, or navigate insurance networks that severely limit specialist options. Language barriers in clinical settings add further complexity for non-English-speaking patients, particularly in Hispanic and other immigrant communities.

Mora outlined several mechanisms she sees as capable of materially reducing these barriers. Telehealth — which expanded substantially during the pandemic and has demonstrated utility in asthma management — allows specialists to reach patients who cannot travel, and she called for continued support for telehealth reimbursement policies that make this access sustainable. Expanded insurance coverage, including coverage for all patients regardless of immigration or income status, was framed as the most foundational change needed. On the technology side, she highlighted 2 developments she sees as particularly promising: ultra-long-acting biologic formulations that reduce the dosing frequency burden and may improve adherence in patients with limited health system touchpoints, and digital smart inhalers that track medication use in real time, allowing clinicians to identify adherence gaps and patients to recognize when controller therapy is being used inadequately.

Environmental determinants received explicit attention. Mora called for reduction in outdoor air pollutants — including ozone and particulate matter — as well as targeted indoor air quality interventions, particularly around household smoking. Both exposures are disproportionately concentrated in urban and lower-income communities, compounding the biologic susceptibility to poorly controlled asthma in precisely those populations that also face the greatest barriers to specialist access and affordable medication. She framed these environmental and structural factors not as background context but as core clinical determinants — ones that clinicians cannot address alone and that require coordinated policy and public health responses.

“I think world asthma day also calls for a day that we have to talk about health equity and disparities in health that we currently exist in the United States,” Mora said.

Office of Minority Health, US Department of Health and Human Services. Asthma and Black/African Americans. Updated 2025. Accessed May 2026. 

https://minorityhealth.hhs.gov/asthma-and-blackafrican-americans

Black Americans bear a disproportionate burden of asthma mortality, and clinicians and policymakers must address a number of factors to make meaningful progress.


Juanita Mora, MD

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