STUDY OBJECTIVES: To quantify the prevalence and impact of chronic respiratory symptoms among predominantly Alaska Native (AN)/American Indian (AI) middle school students. DESIGN: School-based prevalence assessment using the International Study of Asthma and Allergy in Children survey, with supplemental video material and added questions about productive cough, exposure to tobacco smoke, and the functional impact of symptoms. SETTING: The Yukon-Kuskokwim delta region of western Alaska. PARTICIPANTS: A total of 466 children in the sixth to ninth grades, 81% of whom are AN/AI (377 children). INTERVENTIONS: No study intervention. RESULTS: Among the 377 AN/AI children, 40% reported one of the following three categories of chronic respiratory disease: physician-diagnosed asthma, 7.4%; asthma-like symptoms (ALS) without an asthma diagnosis, 11.4%; and chronic productive cough (CPC) without asthma diagnosis or symptoms, 21.5%. Symptom prevalence differed substantially between the largest town in the region and rural villages. After an adjustment for demographic factors, exposure to environmental tobacco smoke, active tobacco smoking, and self-report of atopy, village residents were 63% less likely to have ALS (p = 0.009), and had a twofold greater risk of CPC (p