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We haven’t been yelling from the top of the streets, saying, ‘Look at this!’ loud enough,'” said Richard Fuller, the report’s lead author and the founder and CEO of the nonprofit Pure Earth, which focuses on addressing pollution in low- and middle-income countries.

That’s the takeaway of a report published Tuesday in The Lancet Planetary Health, which analyzed the combined health risks of air, water and toxic chemical pollution in 2019. The results show that pollution is responsible for around 9 million premature deaths each year, or one in six globally. That puts its toll on par with smoking.

Pollution-related deaths have stayed flat worldwide since 2015, according to Fuller’s research. A previous study of his showed that pollution was also responsible for 9 million premature deaths in 2015. But the dominant forms of pollution have changed over time.