Phoenix has once again earned a failing grade from the American Lung Association in the organization’s annual rankings of air quality across the U.S.

According to this year’s State of the Air report, Phoenix is the fourth-smoggiest city in the U.S. Phoenix had no improvement from last year, when the city also ranked fourth-worst for ozone pollution.

Ozone pollution, or smog, comes from tailpipe emissions, power plants and other industrial sources, but it’s exacerbated by heat and sun.

“When we see more vehicles on our road, combined with the extreme heat we experience in Phoenix over the summers, that’s driving up ozone pollution,” said Melissa Ramos, American Lung Association senior manager for clean air advocacy.

Phoenix’s particle pollution worsened in this year’s report. Phoenix now ranks 15th-worst in the nation for particle pollution. Last year, the city ranked 20th-worst.

Phoenix’s hot, dry climate plays a role in particle pollution as well, Ramos said.

“Drought, catastrophic wildfires, dust from construction — all of that also contributes to our particle pollution burden,” Ramos said.

The report emphasizes that poor air quality can contribute to a range of health problems, including asthma, cardiovascular diseases and lung cancer.

Under the Trump administration, the Environmental Protection Agency has recently rolled back several emissions regulations. The report warns those changes could threaten Americans’ health and calls on policymakers to strengthen air quality protections.

“Overturning these rules is a huge public health setback, it’s not only going to increase air pollution and worsen lung and heart diseases, but it’s ultimately going to worsen climate change impacts as well,” Ramos said. “We’re calling on EPA to just prioritize public health again.”