Generating aerosol droplets via the atomization of thin aqueous films with high frequency surface acoustic waves (SAWs) offers several advantages over existing nebulization methods, particularly for pulmonary drug delivery, offering droplet sizes in the 1-5-μm range ideal for effective pulmonary therapy. Nevertheless, the physics underlying SAW atomization is not well understood, especially in the context of thin liquid film formation and spreading and how this affects the aerosol production. Here, we demonstrate that the film geometry, governed primarily by the applied power and frequency of the SAW, indeed plays a crucial role in the atomization process and, in particular, the size of the atomized droplets. In contrast to the continuous spreading of low surface energy liquids atop similar platforms, high surface energy liquids such as water, in the present case, are found to undergo transient spreading due to the SAW to form a quasisteady film whose height is determined by self-selection of the energy minimum state associated with the acoustic resonance in the film and whose length arises from a competition between acoustic streaming and capillary effects. This is elucidated from a fundamental model for the thin film spreading behavior under SAW excitation, from which we show good agreement between the experimentally measured and theoretically predicted droplet dimension, both of which consistently indicate a linear relationship between the droplet diameter and the mechanical power coupled into the liquid by the SAW (the latter captured by an acoustic Weber number to the two thirds power, and the reciprocal of the SAW frequency).