Recent dramatic and deadly increases in global wildfire activity have increased attention on the causes of wildfires, their consequences, and how risk from fire might be mitigated. Here we bring together data on the changing risk and societal burden of wildfire in the US. We estimate that nearly 50 million homes are currently in the wildland-urban interface in the US, a number increasing by 1 million houses every 3 years. Using a statistical model that links satellite-based fire and smoke data to pollution monitoring stations, we estimate that wildfires have accounted for up to 25% of PM2.5 in recent years across the US, and up to half in some Western regions. We then show that ambient exposure to smoke-based PM2.5 does not follow traditional socioeconomic exposure gradients. Finally, using stylized scenarios, we show that fuels management interventions have large but uncertain impacts on health outcomes, and that future health impacts from climate-change-induced wildfire smoke could approach projected overall increases in temperature-related mortality from climate change. We draw lessons for research and policy.