A Johns Hopkins Children’s Center study of more than 23,000 U.S. children reveals that income, race and ethnic origin may play far more potent roles in asthma risk than kids’ physical surroundings.

The study, based on comparison of childhood asthma rates in cities and outside of them, found no differences in asthma risk between children living in urban areas and their suburban and rural counterparts.

“Our results highlight the changing face of pediatric asthma and suggest that living in an urban area is, by itself, not a risk factor for asthma,” says lead investigator Corinne Keet, a pediatric allergy and asthma specialist. “Instead, we see that poverty and being African-American or Puerto Rican are the most potent predictors of asthma risk.”

For several decades now, public health experts have found that certain aspects of urban living—pollution, cockroach and other pest allergens, higher rates of premature births, exposure to indoor smoke—make inner-city children more prone to developing asthma. But while all those factors continue to fuel asthma risk, the investigators say, they may no longer be exclusive to or even predominant in inner-city areas, and the new study findings bear out this phenomenon.

The results, the researchers say, reflect powerful demographic shifts at work, such as increasing poverty in suburban and rural areas, and the movement of racial and ethnic minorities out of inner cities. Therefore, they add, public health interventions should also reflect this changing reality.

“Our findings suggest that focusing on inner cities as the epicenters of asthma may lead physicians and public health experts to overlook newly emerging ‘hot zones’ with high asthma rates,” says Elizabeth Matsui, a pediatric asthma specialist and senior author of the study that appeared in January in the Journal of Allergy and Clinical Immunology.