Air quality is the leading global environmental risk factor for disease. This article focuses on the evidence for the need to develop effective air quality policies for the Pacific Islands region. Factors that have influenced the success and failures of previous and existing environmental policies are considered to help understand necessary future actions. Factors instrumental in resulting in policy failures include nations focusing on economic growth and poorly managing the externalities (i.e. waste and fossil fuel emissions); inappropriate application of aid; a lack of planning; insufficient resources; misunderstanding of risks and conflicts in systems of governance. Successful programs have included capacity building activities in collaboration with traditional land-users; empowering of existing leaders, regional co-operation and local acceptance of financial responsibility. Forward strategizing for more effective leadership in air quality management will require a more co-ordinated approach to address enforcement of environmental policyfrom multiple angles: including raising awareness, provision of viable alternatives, local financial responsibility and the co-operation of different authorities to facilitate enforcement.