Objectives Metered-dose inhalers (MDIs) contain propellants which are potent greenhouse gases. Many agencies propose a switch to alternative, low global warming potential (GWP) inhalers, such as dry powder inhalers (DPIs). We aimed to analyse the impact on greenhouse gas emissions and drug costs of making this switch. Setting We studied National Health Service prescription data from England in 2017 and collated carbon footprint data on inhalers commonly used in England. Design Inhalers were separated into different categories according to their mechanisms of action (eg, short-acting beta-agonist). Within each category we identified low and high GWP inhalers and calculated the cost and carbon impact of changing to low GWP inhalers. We modelled scenarios for swapping proportionally according to the current market share of each equivalent DPI (model 1) and switching to the lowest cost pharmaceutically equivalent DPI (model 2). We also reviewed available data on the carbon footprint of inhalers from scientific publications, independently certified reports and patents to provide more accurate carbon footprint information on different types of inhalers. Results If MDIs using HFA propellant are replaced with the cheapest equivalent DPI, then for every 10% of MDIs changed to DPIs, drug costs decrease by £8.2M annually. However if the brands of DPIs stay the same as 2017 prescribing patterns, for every 10% of MDIs changed to DPIs, drug costs increase by £12.7M annually. Most potential savings are due to less expensive long-acting beta-agonist (LABA)/inhaled corticosteroids (ICS) inhalers. Some reliever inhalers (eg, Ventolin) have a carbon footprint over 25 kg CO2e per inhaler, while others use far less 1,1,1,2-tetrafluoroethane (HFA134a) (eg, Salamol) with a carbon footprint of Conclusions Switching to DPIs would result in large carbon savings and can be achieved alongside reduced drug costs by using less expensive brands. Substantial carbon savings can be made by using small volume HFA134a MDIs, in preference to large volume HFA134a MDIs, or those containing HFA227ea as a propellant.

https://bmjopen.bmj.com/content/bmjopen/9/10/e028763.full.pdf

Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England

http://www.thelancet.com/article/S2666606522000748/pdf

The carbon footprint of hospital diagnostic imaging in Australia

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well‐being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare‐related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well‐established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action‐oriented recommendations, supported by useful resources and success stories. The CODA‐hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence‐based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/anae.15785

Action guidance for addressing pollution from inhalational anaesthetics

Health care is one of the largest and fastest growing service sectors in OECD countries and a significant contributor to climate change. Health care is also indispensable for human well-being. It is therefore crucial to understand how the health care sector can reduce its emissions without undermining its service quality. We break down the carbon emissions of Austrian health care in unprecedented detail over a decade starting in 2005. We calculated the carbon footprints of Austrian health care providers and further decomposed the emissions attributable to hospitals, the largest health care provider in Austria. We estimated detailed life cycle assessments of the carbon emissions attributable to energy use, the use of selected pharmaceuticals and medical goods and induced private travel. The Austrian health carbon footprint amounted to 6.8 million tons of CO2 in 2014, a decline of 14% since 2005, mainly due to the rising shares of renewables in the Austrian energy sector. Complementary calculations of the carbon emissions from energy use by Austrian health care providers confirm this finding. Goods purchased by hospitals, pharmaceuticals and other medical non-durables stand out as especially large contributors to the health carbon footprint. Carbon emissions attributable to induced travel increased by 15%, indicating the need to better align planning of health care provision with transport and spatial planning. Concluding, we argue that many untapped possibilities for reducing the carbon footprint of health care exist and propose six concrete steps towards sustainable health care that are applicable to most industrial countries.

Carbon emission trends and sustainability options in Austrian health care

The medical field causes significant environmental impact. Reduction of the primary care practice carbon footprint could contribute to decreasing global carbon emissions. This study aims to quantify the average carbon footprint of a primary care consultation, describe differences between primary care practices (best, worst and average performing) in western Switzerland and identify opportunities for mitigation.We conducted a retrospective carbon footprint analysis of ten private practices over the year 2018. We used life-cycle analysis to estimate carbon emissions of each sector, from manufacture to disposal, expressing results as CO2 equivalents per average consultation and practice. We then modelled an average and theoretical best- case and worst-case practices. Collected data included invoices, medical and furniture inventories, heating and power supply, staff and patient transport, laboratory analyses (in/out-house) waste quantities and management costs.An average medical consultation generated 4.8 kg of CO2eq and overall, an average practice produced 30 tons of CO2eq per year, with 45.7% for staff and patient transport and 29.8% for heating. Medical consumables produced 5.5% of CO2eq emissions, while in-house laboratory and X-rays contributed less than 1% each. Emergency analyses requiring courier transport caused 5.8% of all emissions. Support activities generated 82.6% of the total CO2eq. Simulation of best- and worst-case scenarios resulted in a ten-fold variation in CO2eq emissions.Optimizing structural and organisational aspects of practice work could have a major impact on the carbon footprint of primary care practices without large-scale changes in medical activities. 

/pdf/what-is-the-carbon-footprint-of-primary-care-practices-a-2hcxnh83.pdf

What is the carbon footprint of primary care practices? A retrospective life-cycle analysis in Switzerland

Climate change - Call to action: Catch The Wave

International environmental health activists have called for public health to take a central role in the UN climate change talks.1 However, despite increasingly dire warnings of the economic and health catastrophes that unabated climate change will cause,2 most health professionals and lay people have not been stirred into the …

Call to action: catch The Wave

Our editorial aimed at alerting health professionals to the role of hydrofluorocarbons in inhalers as greenhouse gases and at stimulating debate on how to mitigate these effects.1 2 

Obviously, conventional strategies to reduce carbon …

https://www.bmj.com/content/bmj/347/bmj.f4164.full.pdf

Authors’ reply to Reynolds

Health professionals are well positioned to effect change by reshaping individual practice, influencing healthcare organisations, and setting clinical standards, argue Jodi Sherman and colleagues

https://www.bmj.com/content/bmj/374/bmj.n1323.full.pdf

Net zero healthcare: a call for clinician action

Propellants in metered dose inhalers are powerful greenhouse gases 

It is five years since the Climate Change Act (2008) was introduced to ensure that by 2050 the United Kingdom cuts its carbon emissions by 80%. Despite this, atmospheric carbon dioxide levels have recently increased, passing the 400 parts per million mark. Although the potential impact of climate change on respiratory health is widely appreciated,1 it is less well known that respiratory drugs may be making a sizeable contribution to global warming because of the propellant gases used in metered dose inhalers.

The NHS has an annual global warming potential of about 20 million tonnes of carbon dioxide equivalent (1 million tonnes of carbon dioxide is equivalent to 1000 kg or 55.6 billion L of carbon dioxide),2 which is about the same as that of Estonia. This constitutes about 3% of total UK emissions, which were 590 million tonnes of carbon dioxide equivalent in 2010. Of this, only 35% is accounted for by heating, lighting, and transport, with 65% being due to procurement—the delivery of healthcare, including drugs.2 Respiratory inhalers are some of the …

https://www.bmj.com/content/bmj/346/bmj.f3359.full.pdf

Inhaled drugs and global warming: time to shift to dry powder inhalers

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