Inhaled therapies are central to effectively treating pulmonary conditions, especially asthma and COPD. Inhaled therapy has a number of advantages over systemic therapy but requires patients to use, and to master the use of, an inhaler device. Unfortunately, 50% to 81% of patients do not use their inhalational devices accurately, with older patients more likely to have poor technique.1 Perhaps more concerning is that many health professionals do not use inhalers accurately and are, therefore, not in a position to assess and coach patients effectively.2 Educating patients in the correct use of their inhalers results in mastery of the skill and improved disease outcomes.1 However, retention of correct technique is challenging, with 50% of patients unable to retain accurate technique over time.3 Despite the development of several new and improved types of inhaler devices, available evidence suggests that little to no progress has been made regarding patients’ ability to accurately use their inhalers. Clearly, this is a complex and widespread problem that we all need to be concerned about and motivated to change. A study by O’Conor and colleagues4 in this issue of CHEST (see page 1307) highlights this complexity and the interplay among a variety of factors by exploring the effect of health literacy and cognitive function on the proper technique of and adherence to controller medications in older patients with asthma.