Air quality in the Balkan capitals remains a defining challenge for the region’s urban sustainability goals. This article explores how pollution, carbon emissions, and weak governance are constraining progress in Western Balkan cities. Despite lower per capita emissions, cities struggle to decarbonize due to fossil fuel dependence and outdated heating and transport systems. Public health impacts are severe, yet policy responses remain fragmented. The piece concludes by calling for a strategic shift from declarations to action to secure a sustainable urban future.