Asthma Capitals 2019: Top 100 National Ranking

The Asthma Capitals ranking is an annual research and educational project of AAFA, designed to help patients recognize, prevent and manage asthma symptoms. Through this ranking, AAFA raises awareness about the impact of asthma and highlights how communities can make improvements to better serve their residents and visitors with asthma.

In AAFA's Asthma Capitals 2019 ReportDownload PDF, we ranked cities based on three health outcomes: asthma prevalence, asthma-related emergency department visits and asthma-related mortality rates. The report also looks at eight risk factors that can affect asthma rates: poverty, lack of health insurance, poor air quality, pollen counts, long-term control medicine use, quick-relief medicine use, smoking laws and access to specialists.

Here are the top 100 metropolitan cities that are most challenging to live with asthma:



Metropolitan Area

1 Springfield, MA
2 Dayton, OH
3 Greensboro, NC
4 Philadelphia, PA
5 Cleveland, OH
6 Allentown, PA
7 Louisville, KY
8 Boston, MA
9 Omaha, NE
10 Milwaukee, WI
11 New Haven, CT
12 Richmond, VA
13 Hartford, CT
14 Akron, OH
15 Jackson, MS
16 Columbus, OH
17 St. Louis, MO
18 Cincinnati, OH
19 Baltimore, MD
20 Winston-Salem, NC
21 Chattanooga, TN
22 Greenville, SC
23 Detroit, MI
24 Buffalo, NY
25 Birmingham, AL
26 New Orleans, LA
27 Albuquerque, NM
28 Washington, DC
29 Memphis, TN
30 Worcester, MA
31 Wichita, KS
32 Oklahoma City, OK
33 Charleston, SC
34 Columbia, SC
35 Toledo, OH
36 Chicago, IL
37 Tulsa, OK
38 Spokane, WA
39 New York, NY
40 Phoenix, AZ
41 Kansas City, MO
42 Bridgeport, CT
43 Nashville, TN
44 Albany, NY
45 Stockton, CA
46 Tucson, AZ
47 Virginia Beach, VA
48 Indianapolis, IN
49 Sacramento, CA
50 Scranton, PA
51 Syracuse, NY
52 Modesto, CA
53 Harrisburg, PA
54 Pittsburgh, PA
55 Boise, ID
56 Little Rock, AR
57 Rochester, NY
58 Durham, NC
59 Las Vegas, NV
60 Des Moines, IA
61 Knoxville, TN
62 Grand Rapids, MI
63 Denver, CO
64 Seattle, WA
65 Providence, RI
66 Madison, WI
67 Jacksonville, FL
68 Atlanta, GA
69 Salt Lake City, UT
70 Raleigh, NC
71 Fresno, CA
72 Portland, OR
73 San Francisco, CA
74 Charlotte, NC
75 Colorado Springs, CO
76 Dallas, TX
77 Austin, TX
78 Oxnard, CA
79 Bakersfield, CA
80 San Diego, CA
81 Augusta, GA
82 Riverside, CA
83 Tampa, FL
84 Baton Rouge, LA
85 Orlando, FL
86 Lakeland, FL
87 Minneapolis, MN
88 Ogden, UT
89 Miami, FL
90 Los Angeles, CA
91 Provo, UT
92 Palm Bay, FL
93 San Jose, CA
94 San Antonio, TX
95 El Paso, TX
96 Daytona Beach, FL
97 Sarasota, FL
98 Houston, TX
99 McAllen, TX
100 Cape Coral, FL

Regional Focus

During our research, we uncovered two eye-opening issues within our top 20 Asthma Capitals. First, all our top 20 Asthma Capitals are in the eastern half of the U.S. Second, there are two clear patterns, or “Asthma Belts,” that emerge when the top 20 Asthma Capitals are plotted on a map. These Asthma Belts indicate that further examination of these areas is needed on local, state and possibly even federal levels to improve asthma outcomes.

Asthma Belts Image

Northeast Mid-Atlantic Asthma Belt

Not only are this year’s top 20 capitals located on the eastern half of the country, many of them are clustered in the Northeast. The belt extends from Massachusetts to North Carolina. Poverty, air quality and access to specialists are key risk factors for these cities. This is likely a product of more industrial and urban populations. Asthma rates tend to be higher, especially among children, in urban locations due to more rental housing, more manufacturing and industrial businesses, and proximity to high-traffic roadways.

Access to asthma specialists in Allentown, Pennsylvania (overall #6 on Asthma Capitals), is a challenge. There are fewer than a dozen asthma specialists in the area. Dr. Robert Zemble is one of them. He is an allergist with Allentown Asthma & Allergy, as well as the Chief of the Division of Allergy at Lehigh Valley Hospital. He treats both children and adults. And he recognizes the “huge impact asthma has on people’s lives.”

“Springtime is particularly hard for a lot of patients around here. The tree pollen season and the grass pollen season is a difficult time for many of our patients,” he explained. “It's one of those things that [can] make it impossible [for them] to enjoy the outside.”

Helping people identify their asthma triggers, such as spring allergies, is an important part of Dr. Zemble’s job. “We want to identify what are their triggers and what is going to affect them,” he shared. This includes “identifying the particular demographics of where they live and how they are going to affect them.”

For example, he looks at a person’s exposure to pollen, insects, dust, poor air quality, pet dander and more. The exposure may depend on where they live. The Allentown area includes both urban and suburban areas. And Dr. Zemble sees people who live in both settings.

People who have asthma often have other medical conditions as well. Dr. Zemble has seen firsthand how “other allergic diseases are associated with the development of asthma. A lot of our patients with asthma also have atopic dermatitis, food allergies, allergic rhinitis and allergic conjunctivitis. Some of the patients are also overweight, and that is a known factor for developing and worsening asthma.”

He works in collaboration with the team at Allentown Asthma & Allergy to teach patients about asthma, how to identify symptoms and how to properly use an inhaler. He points out that proper inhaler use is critical.

“If you don’t [teach people how to properly use their medicine] and they aren’t getting their actual medicine [into their lungs], it doesn’t matter what medicine you prescribe them,” he shared. His advice for other health care professionals is “to really communicate with your patients. Find out what is triggering their asthma. And really educate them on how and why to use their medicines.”

Ohio Valley Asthma Belt

Five Ohio cities are in the top 20 of our report – Akron, Cincinnati, Cleveland, Dayton and Columbus. With so much of Ohio facing poor outcomes, asthma appears to be a widespread concern. Nearby, Louisville appears in this "Asthma Belt." Poverty, pollen, air quality and high numbers of medicine use are the key risk factors that have placed multiple Ohio cities at the top of our report. Most of the Ohio cities in the top 20 Asthma Capitals have a poverty rate that is higher than national average.

Poverty Rates:

  • Cleveland – 18.1%
  • Cincinnati – 16.2%
  • Columbus – 16%
  • Dayton – 15.9%
  • National average - 14%
  • Akron – 12.9%

Poverty rates among children in these cities are even higher, especially among minority populations. Asthma rates among minorities coincide with these poverty rates. In Ohio overall, 16% of Non-Hispanic black children and 11.9% of Hispanic children have asthma, compared to 4.9% of Non-Hispanic white children.

Alisha Hopkins, CNP, is Director of the Lung Health Clinic for The Breathing Association, a free clinic in Columbus, Ohio (overall #16 on Asthma Capitals). The Breathing Association helps people breathe easier through education, detection, care and treatment.

“Our patients live at a level of acceptance,” shared Alisha. She sees people “when they are very short of breath and their level of understanding about asthma is very low.” She works to help them realize that “breathing is not a luxury; it’s a necessity.”

Sometimes when people first come to see her, they are using their quick-relief inhaler four or five times a week. To Alisha, that “is not acceptable. Their asthma symptoms are not controlled.” For various reasons her patients often do not have health insurance. Or they can’t afford the copayments on their medicines.

“When they don’t have health insurance, I can tell,” she shared. “They don’t use the medication as prescribed.” She has had patients who used their grandmother’s inhaler, bought inhalers off the black market and/or spaced out doses of long-term control medicines rather than taking them every day as prescribed.

She often provides patients with sample medicines to help start getting their asthma under control. But she recognizes “a month’s sample is a Band-Aid. It’s not going to work.” So her work doesn’t stop there. “I teach them to use the long-term control inhaler every day. You don’t get the same instant relief as the rescue inhaler, so they think it doesn’t do anything for them.”

But it does. Medicine adherence is a critical part of managing asthma. One of Alisha’s favorite things to hear from a patient at their follow-up appointment is, “I can’t believe it. I haven’t had to go to the ER at all.” And she tells them, “That is exactly what is supposed to happen.”

She also helps people learn how to be aware of their breathing. This includes knowing when and how many times to use their quick-relief inhaler. “A lot of the education we provide is identifying the signs of shortness of breath and when to take action, when to call me and when to go to the ER,” she shared.

Part of the education she provides also includes understanding asthma triggers. In Central Ohio, this includes pollen. “Central Ohio has a very high pollen count. Springtime is when people with asthma are having difficulty secondary to allergies. We must educate them about how asthma can be affected by allergies. I think education is the key to compliance and empowering people to feel that they are in control of their asthma. Because really they are.”