How greater respiratory control could be the key to reducing NHS inhaler carbon footprint
Climate change and the environment are increasingly hot topics. While conversation about emissions is often focused on vehicles, the impact of the healthcare system should not be overlooked.
As a significant contributor to total UK annual emissions, the NHS has a key role to play if the UK is to meet its carbon emissions targets set by the Montreal Protocol in 2017. As such, NHS England has committed to reducing its emissions by 34% by 2020 (based on 1990s levels).1
One area the NHS can influence is the procurement of medicines, especially where equally effective alternative treatments exist. During a 2017-18 inquiry by the parliamentary Environmental Audit Committee, it was identified that respiratory inhalers contribute approximately 3.5% of overall NHS emissions due to the use of fluorinated gas in the propellant of metered dose inhalers (MDIs).2 The Committee challenged the government and NHS to address this by prescribing more low carbon dry powder inhalers (DPIs)2. Published in January 2019, the NHS Long Term Plan supports patients being prescribed DPIs where clinically appropriate.1 The NHS is committed to reducing carbon emissions from inhalers in a way that is not detrimental to patient care.
Why are DPIs important in reducing carbon emissions?
100 doses of an MDI have a carbon footprint roughly equal to a 180-mile drive.8-11 Alternatively, DPIs have a carbon footprint 18 times lower than MDIs.3
In the UK, approximately 70% of all inhaler prescriptions are for MDIs.2 Even small changes in the number of patients instead using DPIs could make a significant difference to the environment.
The UK is below European average when it comes to asthma control and other countries in Europe already use fewer MDIs.2,4 For example, in Sweden, MDIs make up just 10% of the inhaler mix.3,5 Education and awareness of the difference in inhaler carbon footprint of clinically equivalent MDIs and DPIs may help the UK move to a more sustainable inhaler prescribing mix in the future.
The UK is below European average when it comes to asthma control and other countries in Europe already use fewer MDIs. For example, in Sweden, MDIs make up just 10% of the inhaler mix.
How national guidance has changed to reflect low carbon considerations
In July 2019, BTS/SIGN updated its guidance for asthma care and included for the first time a recommendation to use inhalers with a lower carbon footprint – such as DPIs – when they are likely to be equally effective.6 This follows the publication of a NICE Asthma Inhaler Decision Aid in April 2019, which encourages clinicians and patients to consider the environment when deciding on inhaler choice.8
With formal guidelines and NHS plans advocating low carbon inhalers, and with DPIs more likely to be used correctly than MDIs3, there is a strong case for considering them for patients unless there is a clinical reason not to. Clinicians that already support DPI use now have an additional reason to discuss suitability with patients. Ultimately, moving patients to DPIs could help the NHS meet its target to tackle inhaler emissions.
Greater asthma control should continue to be the most important factor in supporting a patient to improve their inhaler use. However, improved control can also have a positive impact on the environment, for example, if patients are supported to reduce the use of short acting bronchodilator inhalers and are offered DPIs where clinically appropriate, they will use significantly less fluorinated gases than traditional MDIs.1
This important co-benefit is an even more important reason to ensure patients come in for review and have the right education and awareness of the range of inhalers, including understanding their carbon footprint.
- NHS: The NHS Long Term Plan.
- House of Commons Environmental Audit Committee. UK progress on reducing F-gas emissions.
Hillman, T. Mortimer, F and Hopkinson, N. Inhaled drugs and global warming: time to shift to dry powder inhalers. British Medical Journal 2013; 346: f3359
Committee on Climate Change. Net Zero Technical Report. May 2019.
Asthma UK. The reality of asthma care in the UK. Annual Asthma Survey 2018 report.
British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN158 2019. British guideline on the management of asthma.
Labiris NR. Pulmonary drug delivery. Part II: The role of inhalant delivery devices and drug formulations in therapeutic effectiveness of aerosolized medications. British Journal of Clinical Pharmacology 2003; 56: 600–612.
NICE National Institute for Healthcare and Excellence: asthma patient decision aid.
2014 Report of the United Nations Environment Programme Medical Technical Options Committee.
2017 National Travel Survey, UK Department for Transport.
Greenhouse gas reporting conversion factors 2018, gov.uk.