Sustainability

The environmental impact of respiratory treatment

While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception.

It has been shown that patients consider the environmental impact of their treatment to be important,² but just how significant is the environmental impact of inhalers?

Currently available pressurised metred dose inhalers (pMDIs) contain propellants that are potent greenhouse gases and harmful to the environment.³ The use of rescue salbutamol pMDIs in Italy, Spain, France, Germany and the UK is estimated to produce 1,791,312 tonnes CO₂ eq per year,⁴ equivalent to:

• 4.5 billion miles driven in a car⁵ or
• the electricity to power more than 215,000 homes for a whole year⁵

However, dry powder inhalers (DPIs) and soft mist inhalers (SMIs) do not contain propellant and are described as ‘low carbon inhalers’.⁶ Based on UK prescribing data, switching all pMDIs (containing HFC-134a, -227ea and -152a propellants) to DPIs would lead to a 96% reduction in climate change impact.⁷

Successful management of disease can reduce the carbon footprint of respiratory treatment

Patients with uncontrolled asthma typically have increased rescue medication use and often experience severe exacerbations, which may lead to emergency room (ER) visits, hospitalisations, and ambulance trips. All of these are associated with substantial greenhouse gas (GHG) emissions,^8,9 meaning that well-managed disease would lead to a reduction in the overall carbon footprint (CFP) a patient’s therapy.

To find out more about how reduced ER visits and rescue medication use may lead to lower carbon emissions, see the ATS 2021 poster presentation in section 5.⁸

To find out more about how severe asthma exacerbations may contribute a large carbon footprint as a result of ambulance trips, ER visits and hospitalisations, watch the ERS 2021 oral presentation in section 4.⁹

Pharmaceutical companies are committed to reducing their environmental impact

There are several global organisations (such as the World Health Organisation) and national healthcare organisations (such as the National Health Service in the UK) who are setting targets to reduce our global impact on the environment.

In addition to this, pharmaceutical companies are seeking ways to reduce the environmental impact of all aspects of their supply chain. The most recently published values indicate that pMDI manufacture and use accounts for 13% of total carbon emissions for AstraZeneca and 36% for GSK.^10,11 As such, a number of life cycle assessments (LCAs) have been carried out, which take into account all stages of inhaler development.

Novartis carried out an LCA for their BREEZHALER DPI and found that it has a low carbon footprint.¹² More information on the Novartis BREEZHALER LCA can be found in section 6. Data are published here:

Fulford B, Mezzi K, Whiting A, et al. Life-Cycle Assessment of the Breezhaler® Breath-Actuated Dry Powder Inhaler. Sustainability 2021;13(12):6657

References

1. The Lancet. The Lancet Countdown on health and climate change: Tracking progress on health and climate change. Last accessed August 2021. Available from: https://www.thelancet.com/countdown-health-climate/about.
2. Metting EI, Van Dijk L, El Messlaki H, et al. Development of a shared decision-making tool to support patients and their healthcare provider in choosing the best inhaler device. Eur Respir J 2018;52(suppl 62):OA1643.
3. Wilkinson AJK, Braggins R, Steinbach I, et al. Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England. BMJ Open 2019;9(10):e028763.
4. Wilkinson A, Menzies-Gow A, Sawyer M, et al. S26 An assessment of short-acting β2-agonist (SABA) use and subsequent greenhouse gas (GHG) emissions in five European countries and the consequence of their potential overuse for asthma in the UK. Thorax 2021;76(Suppl 1):A19-A19.
5. United States Environmental Protection Agency (US EPA). Greenhouse Gas Equivalencies Calculator. Last accessed August 2021. Available from: https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator.
6. British Thoracic Society. Environment and Lung Health Position Statement, 2020. Last accessed September 2021. Available from https://www.brit-thoracic.org.uk/about-us/governance-documents-and-policies/position-statements/.
7. Jeswani HK, Azapagic A. Life cycle environmental impacts of inhalers. J Clean Prod 2019;237(117733).
8. Beeh KM, Van Zyl Smit R, Mezzi K, et al. Emergency Room Visits and Rescue Medication Use in Patients with Asthma in the IRIDIUM Study and Their Impact on Carbon Footprint. American Thoracic Society (ATS) 2021 (Abstract).
9. Beeh KM, Aumônier S, Whiting A, et al. OA102: Carbon footprint of severe asthma exacerbation management relative to Breezhaler dry powder inhaler. European Respiratory Society (ERS) 2021 (Abstract).
10. AstraZeneca. Sustainability Report 2019, 2019. Last accessed September 2021. Available from https://www.astrazeneca.com/content/dam/az/Sustainability/2020/pdf/Sustainability_Report_2019.pdf.
11. GlaxoSmithKline (GSK). Understanding our value chain carbon footprint. Last accessed September 2021. Available from https://www.gsk.com/media/3632/detailed-carbon-value-chain.pdf.
12. Fulford B, Mezzi K, Whiting A, et al. Life-Cycle Assessment of the Breezhaler^® Breath-Actuated Dry Powder Inhaler. Sustainability 2021;13(12):6657.

Environmental symposium ERS 2021

A greener future for asthma medicine: a step forward

Welcome to this Novartis-sponsored symposium in which leading experts Professor David Price (chair), Professor Ashley Woodcock and Dr Kai Beeh give a call to action about climate change and the environmental impact of different inhaler devices, and the potential ways to make asthma management more sustainable. The symposium ends with a lively discussion between faculty on the environmental impact of inhaler choice and the key issues discussed in previous presentations.

Protecting the planet: time for action!

Welcome to this highly topical Novartis-sponsored symposium in which leading experts Professor Ashley Woodcock (chair), Professor Rachel Huxley and Dr Kai Beeh discuss the likely effects of climate change on human health, and respiratory illness in particular. The panel also discuss the potential environmental impact of different inhaler devices, highlighting the environmental impact from Metered Dose Inhalers (MDIs) and Dry Powder Inhalers (DPIs).

Introduction

Professor Ashley Woodcock (UK) provides an overview of the agenda and introduces the faculty

Climate change: its impact on health and disease

Professor Rachel Huxley (Australia) outlines the social, economic and health impacts air pollution and global warming are already having. She highlights that ambient air pollution is worsened by climate change and also exacerbates asthma and may contribute to new onset asthma. There is therefore an imperative to reduce emissions in order to help reduce the associated health burden and population health threat due to climate change.

Our patients and our planet: considerations for inhaler choice

Professor Woodcock (UK) focusses the discussion on inhalers for respiratory conditions, highlighting the contribution of MDIs to the total carbon footprint of health care systems such as the UK National Health Service. He emphasizes areas in which the carbon footprint of inhalers could be lowered, including the use of DPIs where clinically relevant and acceptable to the patient.

Time to focus on green inhalers

Dr Kai Beeh (Germany) discusses the importance of taking inhaler carbon footprints into account when choosing an inhaler. Patients should receive the best treatment to control their asthma according to approved label and clinical evidence and should be offered information about the carbon footprint of their inhalers.

Panel discussion

Join the faculty for an interactive session as they take an in depth look at key questions on the environmental impact of inhaler choice raised by the issues discussed in previous presentations.

Carbon footprint of exacerbations ERS 2021 oral presentation

View the oral presentation given by respiratory expert Dr Kai Beeh at ERS 2021: “Carbon footprint of severe asthma exacerbation management relative to Breezhaler dry powder inhaler”.

Dr Beeh presents results from a study to report the estimated carbon footprint of managing severe asthma exacerbations as a basis for establishing net benefits of using the HFC/CFC-free Breezhaler^® DPIs.

Carbon footprint of ER visits and rescue medication use: IRIDIUM ATS 2021 poster

Emergency Room Visits and Rescue Medication Use in Patients with Asthma in the IRIDIUM study and their Impact on Carbon Footprint

Kai-Michael Beeh, Richard N. van Zyl-Smit, Karen Mezzi, Simon Aumônier, Abhijit Pethe, Peter D’Andrea, Ashley Woodcock

View this poster presented at ATS 2021 to learn more about the carbon footprint of ER visits and rescue medication use in the IRIDIUM Phase III study. Results indicate that effective DPIs may reduce the need for rescue medication vs pMDIs, and therefore would also reduce the patient’s carbon footprint.

LCA sustainability paper: Medical summary slides

Life-Cycle Assessment of the Breezhaler^® Breath-Actuated Dry Powder Inhaler

Brett Fulford, Karen Mezzi, Andy Whiting, Simon Aumônier

This comprehensive assessment of the Breezhaler^® dry powder inhaler (DPI) evaluated three variants of the DPI, assessing them across six key environmental impact categories, including: global warming potential, ozone depletion and resource use. The study was designed to identify major hotspots in the life cycle. View the slides to find out more about the environmental impact of the Breezhaler^® DPI.