A number of important considerations arise from this study. The first is that asthma continues to be very poorly controlled. The fact that the study population entered the trial with persistent symptoms (nocturnal symptoms, > 60% of patients; visit to an emergency department in the previous month, > 25% of patients) and airflow obstruction, yet < 50% of these patients reported being treated with inhaled corticosteroids (ICSs), continues to be a very depressing statistic. Second, the number of patients who were actually using their ICSs as prescribed was never documented. This leads to the third consideration, which is whether the combination of ICSs and LABAs carries the same risk to patients as using LABAs as monotherapy (ie, the majority of patients in the SMART study). The great weight of evidence suggests that this is not the case. All studies (mostly large, prospective, placebo-controlled, and randomized) that have evaluated the effects of therapy with either of the two currently available combinations of ICSs and LABAs (ie, salmeterol/fluticasone or formoterol/budesonide)7–10 have demonstrated a reduction, often as much as 50%, in severe asthma exacerbations or severe asthma-related events. Thus, it is highly improbable that combination therapy carries the same risks to patients as that of monotherapy with LABAs. Fourth, the African-American population had more severe asthma than the population as a whole, with lower lung function, with 67% of the patients having experienced nocturnal symptoms, 41% having visited an emergency department in the previous month, and with fewer patients prescribed ICSs. Thus, it is unclear whether the increased risks that this population experienced was because of this increased disease severity or because of other factors, possibly genetic, such as an increased prevalence of the Arg-Arg polymorphism at position 16 of the β2-receptor. These issues require further consideration. A final issue is whether the concerns raised by the SMART study are applicable to all LABAs. Another study published in this issue of CHEST (see page 27) by Wolfe et al11 suggests that this may not be the case for inhaled formoterol, which has a somewhat different pharmacologic profile when compared to that of salmeterol.12 This randomized placebo-controlled study compared higher dose formoterol (24 μg twice daily) to lower dose formoterol (12 μg twice daily), with or without up to 12 μg twice daily used as rescue therapy, to placebo in > 2,000 patients for 4 months of therapy. The study confirmed the efficacy of formoterol as a bronchodilator but did not demonstrate any increase in severe asthma-related events or asthma deaths with formoterol treatment.