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It’s been well documented that while climate change affects everyone, its impact is not evenly shared. In the U.S., black and Latinx communities have been disproportionately hit by environmental disasters like storms and flooding; and a number of recent reports have found even the air they breathe isn’t safe.

A new report by the American Lung Association adds to a growing body of research on air pollution—including who is most impacted, and the ways it erodes the health of vulnerable communities.

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In their 20th Annual “State of the Air” report, published on Wednesday, the ALA offers a comprehensive look at air pollution in cities and counties across the country. The report grades and ranks cities on their levels of air pollution. It also delves into the health impacts of poor air quality and the challenges Americans face in combating air pollution.

The facts are dire.

“Many Americans, and many of the most vulnerable Americans, are currently living in environments with high or extremely poor air quality,” Dr. David Tom Cooke, head of lung surgery at UC Davis Health and ALA spokesperson, told The Root.

According to the new ALA study, 4 out of 10 Americans—approximately 141 million—are currently living in areas of unhealthy air. And as the study points out, even short-term exposure or temporary “peaks” or “spikes” in poor air quality can wreak havoc on your health.

“It can lead to premature death. It could lead to exacerbation of asthma. It can lead to lung cancer and cardiovascular disease,” Cooke said.

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On a global scale, climate change is exacerbating air pollution. And nationally, the health of vulnerable populations, like low-income communities and black and Latinx Americans, are hit disproportionately hard by poor air quality.

To understand how, Cooke unpacks the two major components of air pollution: ozone and particulate matter. Ozone, a gas, gives your lungs “the equivalent of a sunburn,” Cooke says. This gas damages the lining and tissue of your lungs, impairing respiratory functions. Then there’s air particulates, or soot, which enter your lungs and then go into the bloodstream, affecting your entire body.

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While air pollution affects everyone, Cooke says, there are populations more vulnerable to exposure and adverse health effects. The young and elderly are particularly vulnerable groups, as are people with preexisting conditions. Low-income communities and communities of color are also among the most vulnerable groups in America—and the reasons are multi-factorial, Cooke explains.

There’s proximity to polluted areas: throughout the U.S., black and Latinx communities tend to live near high pollution zones. Cooke cites California’s Central Valley, home to a substantial Latinx population, as one example. Many black Americans also tend to live near high transportation zones where they inhale a lot of exhaust and diesel fumes, he adds.

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But even if black and Latinx Americans don’t live in high pollution zones, they’re still disproportionately vulnerable to particulate matter and unhealthy air because they’re more likely to have preexisting conditions.

“We do know that in the African American community and many Latinx communities, there’s a high predilection for diabetes and a higher predilection for asthma,” Cooke explains.

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In 2014, black Americans were almost three times more likely to die from asthma than non-Hispanic whites. Recent studies have shown black adults are nearly two times more likely than white adults to develop type 2 diabetes. And that gap has only grown over the last several decades.

Cooke says air pollution compounds a number of health issues that adversely affect black Americans.

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“This is all part of a sort of gumbo of unhealthiness, right?” he said. “Some of it is implicit bias in regard to the care that folks from those at-risk communities get. Some of it are the predilections to certain chronic diseases such as diabetes, asthma, cardiovascular disease, and other types of cancer. And third is the environment in which many people live, and this includes unhealthy air as identified by the report.”

The ALA report builds on previous studies that illuminate how and to what degree black and Latinx communities are impacted by air pollution. Among the most noteworthy studies was one recently published in the journal Proceedings of the National Academy of Sciences (PNAS), which found that while white Americans contributed more to air pollution, black and Latinx communities disproportionately inhaled unclean air.

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But not all the news is bad news, Cooke points out. While several California cities still top the list of most polluted areas in America, over the last ten years, air pollution in these cities—the amount of ozone and particulate matter—has actually dropped, in large part thanks to legislation like the Clean Air Act and advocacy specifically targeted at improving air quality.

But even if state and federal legislatures make air pollution a priority, they have to contend with one major foe: climate change. Cooke notes that 2015, 2016, and 2017 were the three warmest years in recorded history—and higher temperatures exacerbate poor air quality in a number of ways.

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“These warmer temperatures, wildfires, [and] changing weather patterns all lead to increased levels of ozone and particulate pollution,” Cooke said.

Take wildfires, like the Mendocino Complex Fire in California last year—the largest in the state’s history.

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“Wildfires do markedly increase with particulate air pollution, and that again affects asthma, that affects diabetes, that effects cardiovascular disease and predisposition to potential cancer,” Cooke explained.

“So climate change is real, and it’s affecting air quality.”