Belkhir L, Elmeligi A Carbon footprint of the global pharmaceutical industry and relative impact of its major players. J Clean Prod. 2019; 214:185-194

James CLondon: Picador; 2011

Parker J Barriers to green inhaler prescribing: ethical issues in environmentally sustainable clinical practice. J Med Ethics. 2022; 0:1-7

Roy C The pharmacist's role in climate change: A call to action. Can Pharm J. 2021; 154:(2)74-75

Spooner R, Glover Williams A, Roome C Improving the environmental sustainability of paediatric care. Arch Dis Child Educ Pract Ed. 2022; 0:1-7

Wilkinson A, Maslova E, Janson C Environmental Sustainability in Respiratory Care: An Overview of the healthCARe-Based envirONmental Cost of Treatment (CARBON) Programme. Adv Ther. 2022; 39:2270-2280

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Considering green inhalers

02 October 2022
Volume 4 · Issue 10


With metered dosed inhalers accounting for 4% of UK NHS's overall carbon footprint, George Winter discusses the practicalities of switching to more carbon friendly options and the hurdles that still have to be tackled

Belkhir and Elmeligi (2019) found that the pharmaceutical industry ‘is significantly more emission-intensive than the automotive industry', so it is unsurprising that Roy (2021) addressed pharmacists in her ‘call to action'. Noting that greenhouse gases (GHGs) are generated by pharmaceuticals throughout their lifecycle, Roy (2021) cites evidence that metered-dose inhalers (MDIs) account for 4% of the UK NHS's overall carbon footprint, with MDI's propellants being potent GHGs. According to UK data, ‘one patient's inhalers for 1 year (3 salbutamol inhalers at 28 kg CO2 equivalent [CO2 e] each and 12 controller inhalers at 19 kg CO2 e each) are equivalent to driving a car 3200 km’ (Roy, 2021).

Many will welcome the recently announced healthCARe-Based envirONmental cost of treatment (CARBON) programme, which ‘aims to provide a broader understanding of the carbon footprint associated with respiratory care', with Wilkinson et al (2022) asserting that the CARBON programme will quantify the carbon footprint of medications and healthcare resource utilisation among 2.5 million patients with respiratory diseases from seven current studies in over 40 countries. However, Spooner et al (2022) warn that decreasing GHG emissions should not be at the expense of compromising patient outcomes.

This aspect was recently tested. Acknowledging that the carbon footprint of a dry powder inhaler (DPI) can be 20–200 times less than that of an MDI, Woodcock et al (2022), in this UK study, evaluated the effects on carbon footprint and asthma control of patients switching maintenance therapy from an MDI to a DPI compared to those who continued with MDI-based treatment. They found that patients switching from an MDI- to a DPI-based maintenance therapy ‘more than halved their inhaler carbon footprint without loss of asthma control’ and conclude that switching from an MDI to a DPI ‘is an acceptable and worthwhile option for most patients managed in normal everyday practice’ (Woodcock et al, 2022).

However, Parker (2022) has identified ethical issues in relation to environmentally friendly inhaler prescribing in the context of sustainable clinical practice. Noting that in 2020 the NHS was the world's first healthcare system to commit to becoming net carbon neutral by 2040 for emissions under its direct control, Parker (2022) highlights two ethical issues that could compromise a move away from MDIs: patients who decline an inhaler with a smaller carbon footprint and increased cost.

In relation to the former, Parker (2022) identifies a tension between individual GHG emissions and climate change harms, summarised in two salient features of climate change: dispersion of cause and effect – separated in both time and space – and fragmentation of agency, which refers ‘to the fact that the actions of a single emitter do not alone cause global warming.’ However, since DPIs are a comparatively effective, and acceptable, alternative Parker (2022) asserts that ‘a patient is not necessarily morally justified in declining a DPI.’

As for cost, Parker (2022) makes the point that while changing MDIs to certain DPI brands could cost an annual extra £12.7 million for every 10% of MDIs changed, ‘[t]argeted prescribing of the cheapest equivalent DPI instead of certain MDIs could lead to cost savings: £8.2 million annually for every 10% of MDIs', but the potential for DPIs to increase costs for the NHS is nevertheless evident. However, given that the burden of paying for unmitigated global warming will be shouldered by the vulnerable and those least able to pay, Parker (2022) is clear that ‘if MDIs contribute to global warming, then the NHS should pay the cost of mitigation including the cost of using more expensive inhalers.’

In thinking of how we might best meet the challenges of what is now widely considered to be the ‘problem of climate change’ it would be a retrograde step to abandon the rigours of scientific inquiry while opinions are sifted. Identifying what he considered to be a widespread belief that anyone who did not think the climate was in crisis must be in the pay of an oil company, Clive James (2011) observed that being sceptical about the alarmist version of global warming was viewed by some as a general scepticism against science itself. There is no harm in pharmacists applying healthy scepticism to the scientific process in all branches of science … including climate science.