Download PDFPDF

Carbon footprint impact of the choice of inhalers for asthma and COPD
Compose Response

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g.
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests


  • A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
  • We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
  • Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
  • By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

  • Published on:
    British Thoracic Society (BTS) position statement on environmental and lung health
    • Mark Levy, General Practitioner Locum
    • Other Contributors:
      • Christopher Corrigan, Consultant Physician
      • Jane Scullion, Consultant Respiratory Nurse
      • Omar Usmani, Reader in Respiratory Medicine & Consultant Physician
      • Richard Dekhuijzen, Professor of Pulmonology
      • Soren Pedersen, Professor of Pediatric Respiratory diseases
      • Peter Barnes, Margaret Turner-Warwick Professor of Medicine Airway Disease Sectio

    In a position statement published in March, the British Thoracic Society (BTS) recommended that ‘where a new class of inhaler is commenced, this is a Dry Powder Inhaler (DPI)’. The statement went on to state that ‘ Where patients are using several classes of inhalers and poor inhaler technique is identified with one device, that the DPI class is prioritised if the patient is able to use these safely. Similarly, future and
    additional inhalers would ideally also be DPIs; and that during all respiratory reviews, prescribers
    recommend low carbon alternatives to patients currently using Pressured Metered Dose Inhalers
    (pMDIs), where patients are able to use these safely’.

    We are extremely worried by the potential impact that these recommendations could have, since they come from a trusted body which has the reputation to place the health, needs and safety of patients above all. This statement encourages prescribers to change their prescribing habits, not to patient care and safety, but to the systematic exclusion of metered-dose inhalers in favour of dry powder devices for highly debatable environmental concerns. Since the vast majority of prescribers are not experts of inhalation therapy, such guidance may put some patients in danger and lead to a loss of opportunity to optimize care.

    Metered-dose inhalers are used much more reliably with spacers by young children and those with impaired respiratory function. It is well established (1) that pat...

    Show More
    Conflict of Interest:
    None declared.
  • Published on:
    Carbon footprint impact of the choice of inhalers for asthma and COPD. Response to letter from Murnane et al.
    • Christer Janson, Professor, physician Department of Medical Sciences: Respiratory, Allergy & Sleep Research, Uppsala University, Sweden
    • Other Contributors:
      • Richard Henderson, Environmental lead
      • Magnus Löfdahl, Medical lead and physician
      • Martin Hedberg, Meteorologis
      • Raj Sharma, Director of Respiratory Science
      • Alex Wilkinson, Physician

    Dear Editor

    We thank Professor Murnane and co-authors for their comments on our paper: “The carbon footprint impact of the choice of inhalers for asthma and COPD” [1]. Unfortunately, there are some misunderstandings in their letter and we are happy to try to resolve them.

    1. Our study was intended to look at a high-level model for carbon savings in respiratory care, using existing device options with recognised limitations for wider application. It is not a blueprint for system change or a fully costed recommendation for health decision makers. We do not think that it is realistic to change the prescribing patterns from the current 70% pMDIs in England to Swedish levels. We do, however, think it is important to illustrate the potential GWP gains that can achieved if the suggestions in the BTS statement on ‘the environment and lung health’ and the sustainability ambitions of NHS England in its Long Term Plan (7) are followed: “Complete elimination of pMDIs may not be possible due to patient preference and the need to generate sufficient inspiratory flow to activate the DPIs. However, BTS encourages all prescribers and patients to consider switching pMDIs to DPIs whenever they are likely to be equally effective.” (5).

    2. The Murnane et al response refers to content which is not in our paper, such as ‘switching pMDIs to the cheapest DPIs’. The paper does not analyse or compare the costs of switching as this is outside the scope of the study. While th...

    Show More
    Conflict of Interest:
    CJ reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline plc., Novartis and TEVA outside the submitted work; MH reports honoraria from GlaxoSmithKline plc. for presenting scientific data on climate change; AW has nothing to disclose; RH and RS are GlaxoSmithKline plc. employees and hold GlaxoSmithKline plc stocks/shares, ML is an employee of GlaxoSmithKline plc.
  • Published on:
    Carbon footprint, environmental impact, and patient outcomes in inhalation therapy: No simple solution to the complex challenges
    • Darragh Murnane, Lead Contributor and Professor of Pharmaceutics University of Hertfordshire, School of Life and Medical Sciences, Hatfield, UK
    • Other Contributors:
      • Jane Scullion, Lead Contributor , and Respiratory Nurse Consultant
      • Mark L Levy, General Practitioner
      • Peter J Barnes, Professor of Medicine, Honorary Consultant Respiratory Physician
      • Mark Sanders, Chief Technology Officer
      • Toby GD Capstick, Consultant Respiratory Pharmacist, Chair UK Clinical Pharmacy Association Respiratory Group
      • Louise Fleming, Clinical Senior Lecturer and Honorary Cconsultant Paediatric Respiratory Physician
      • Christopher Corrigan, Professor of Asthma, Allergy & Respiratory Medicine
      • Omar S Usmani, Reader in Respiratory Medicine and Consultant Physician

    It was with great interest and not a little concern that we read the recent Brief Communication by Janson and colleagues [1] into the impact of pressurised metered dose inhalers (pMDIs) on the global warming potential (GWP) of respiratory care. We note the tenacity of one of the authors who has succeeded in publishing a second paper [2] based on a similar, flawed logic just two weeks later. The sense of proportion that is missing in both reports has, thankfully, been identified in the press this week.[3] However, we feel it essential to scrutinise the current contribution scientifically.

    The authors report the carbon footprints of a range of devices marketed by GlaxoSmithKline (GSK) following analysis undertaken by the Carbon Trust (a UK not-for dividend company). Subsequently, calculations were undertaken aimed to determine how the carbon footprint of inhalation therapy in the UK’s National Health Service (NHS) might be reduced by altering the prescribing patterns of UK physicians (where more pMDIs are prescribed than dry powder inhalers (DPIs)) to resemble those of Swedish physicians (where the converse holds). While we acknowledge the authors’ declaration that their data are potentially flawed by the fact that their calculations are based on extrapolating the carbon footprints of just three device formats manufactured by one company to predict the effects of total DPI and pMDI usage in the UK when the carbon footprints of most other devices are unknown, we wou...

    Show More
    Conflict of Interest:
    DM reports: Director of Fluid Pharmaceuticals, Deputy Director of EPSRC Centre for Doctoral Training in Aerosol Science, has received research funding or support from Astra Zeneca, Bespak, Cheisi, Clement Clarke International, GlaxoSmithKline, HarroHoffliger, Intertek Melbourn, Teva, Team Consulting, Malvern Panalytical, Zeiss, 3M Ltd., has received consultancy fees, speaker’s fees or hospitality from Adare Pharmaceuticals, DDL/Aerosol Society, Inhalation Asia, MedPharm Ltd. Talipharma Ltd., AstraZeneca, RDD.

    JS: Director of Education for UKIG, ADMIT member I have received support or honoraria from Association of Respiratory Nurse Specialists, AstraZeneca, Boehringer Ingelheim, Chiesi, MIMS, Napp Pharmaceuticals, Mundipharma, Pfizer, Novartis, Primary Care Respiratory Society, NIP, & Haymarket Medical

    MLL Reports : consultancy /advisory board fees from National Services for Health Improvement, Clement Clarke International ,AstraZeneca, Orion,Trudell, Boeringer Ingelheim, Conzorcio Futuro In Ricerca, Novartis Pharmaceuticals, GLaxo Smith Klein , TEVA. Speaker fees from Teva, AstraZeneca, Chiesi, Orion, Menarini, Travel reimbursement for attending meetings from GINA, outside the submitted work.

    PJB reports: Research funding from AstraZeneca and Boehringer-Ingelheim; scientific advisory boards/consultancies from AstraZeneca, Boehringer-Ingelheim, Novartis, Pieris, speaker fees from AstraZeneca Boehringer-Ingelheim, Chiesi, Menarini, Novartis, Teva.

    MS reports: CCI has received funding payments in respect of inhaler training development from an Innovate UK grant awarded to Clin-e-cal. CCI has supplied inhaler training tools to GSK, Astra Zeneca, Boehringer Ingelheim, Teva, Menarini, Mundipharma, Napp, Chiesi, Novartis, Orion and Mylan.

    TGDC reports: Chair of the UK Clinical Pharmacy Association Respiratory Group, member of the UK Inhaler Group. Payment received for educational events and conference sponsorship from: Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Napp, Novartis, Pfizer, Teva.

    LF is an Asthma UK Senior Clinical Fellow. She reports fees for expert consultation and speakers fees from Astra Zeneca, GSK, Novartis, Teva, Boehringer Ingelheim, Respiri and Sanofi paid direct to her institution and outside of the submitted work

    CC reports no conflicts.

    OSU has received industry to academic funding from Boehringer Ingelheim, Chiesi, Edmond Pharma, GlaxoSmithKline, and Mundipharma International, and has received consultancy or speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Edmond Pharma, GlaxoSmithKline, NAPP, Novartis, Mundipharma International, Pearl Therapeutics, Roche, Sandoz, Takeda, Trudell Medical, UCB, and Vectura.