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Pressurised metered dose inhalers (pMDI) contain hydrofluorocarbon (HFC) propellants that do not have an effect on the ozone layer but are powerful greenhouse gases and can contribute to global warming.
Dry powder inhalers (DPI) do not use these propellants and have substantially lower global warming potential, producing 20g CO2 equivalent (CO2eq) per dose compared with 500g CO2eq for some pressurised metered dose inhalers.
Estimated carbon footprints for comparison indicate an average trip (9 miles) in a typical car produces 2,610g CO2eq (or 290g CO2eq per mile).
As Breath Actuated Inhalers (BAIs) contain the same propellants as pMDIs, the estimated carbon footprints for pMDIs can reasonably be extrapolated to BAIs. Available data consistently show that there is a significant difference between DPIs and pMDIs / BAIs, and due to the absence of HFC propellants, DPIs have a low carbon footprint compared to other inhalers.
The Respimat device is a soft mist inhaler (SMI) that does not contain propellants, and so also has a lower carbon footprint than pMDIs and BAIs.
pMDI use in England is responsible for nearly 1 million tonnes of CO2 equivalent per year.
The NHS Long Term Plan identifies a shift to lower carbon inhalers as a way of significantly reducing the carbon footprint of health and social care.
With this in mind, dry powder inhalers or soft mist inhalers are generally preferred locally, unless there is a specific clinical or dexterity reason that an individual requires a pMDI or BAI.
In young children, a pMDI and a spacer is the preferred method of delivery; a face mask is required until the child can breathe reproducibly using the spacer mouthpiece. A pMDI plus spacer is also recommended for patient of any age for the treatment of mild and moderate acute asthma attacks. Other factors to consider include the choice of drug, patient preference, and acquisition cost.
NICE has produced a patient decision aid to help people with asthma and their healthcare professionals discuss their options for inhaler devices (available here), which includes consideration of the carbon footprint of the inhaler. It is suitable for use by people aged 17 years and over, and many of the considerations are also applicable to patients with COPD.
Data on the actual carbon footprint of individual inhalers is very limited, therefore the following tables provide indicative rather than actual values. The figures are based on usual daily doses recommended in the Devon Formulary and median CO2eq values per inhaler as estimated by PrescQIPP. Equivalent care miles for comparison have been estimated on the basis of an average trip (9 miles) in a typical car producing 2,610g CO2eq (or 290g CO2eq per mile) (see NICE).
These figures are intended to highlight the environmental impact of inhaler devices containing hydrofluorocarbon (HFC) propellants compared to dry powder / soft mist inhalers. When relevant clinical factors have been taken into account, the potential environmental benefits of selecting products with lower CO2eq per puff and/or dosing regimens that require fewer puffs per day are also noted.
| Active ingredient | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Terbutaline | Bricanyl Turbohaler | 4.1 | Up to 4 puffs | Up to 5.99 | Up to 21 |
| Active ingredient | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Salbutamol | Salamol CFC-free (pMDI) | 60.4 | Up to 8 puffs | Up to 176.37 | Up to 608 |
| Salbutamol | Salamol Easi-breathe (BAI) | 59.8 | Up to 8 puffs | Up to 174.62 | Up to 602 |
| Salbutamol | Airomir Autohaler (BAI) | 48.6 | Up to 8 puffs | Up to 141.91 | Up to 489 |
Ventolin Evohaler 100 micrograms is a non-formulary product. The CO2eq per puff is 141 grams. The equivalent annual car miles for a daily dose of up to 8 puffs is up to 1,420 car miles.
| Active ingredient | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Formoterol | Formoterol Easyhaler | 4.53 | 2 puffs | 3.31 | 11 |
| Formoterol | Oxis Turbohaler | 6.17 | 2 puffs | 4.50 | 16 |
| Indacaterol | Onbrez Breezhaler | 18.75 | 1 puff | 6.85 | 24 |
| Salmeterol | Serevent Accuhaler | 12 | 2 puffs | 8.76 | 30 |
| Active ingredient | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Formoterol | Atimos Modulite | 130 | 2 puffs | 94.9 | 327 |
| Salmeterol | Soltel | 130 | 4 puffs | 189.8 | 654 |
| Active ingredient | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Ipratropium bromide | Atrovent | 73 | 3 to 8 puffs | 79.94 to 213.16 | 276 to 735 |
| Active ingredient | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Tiotropium | Braltus Zonda (DPI) | 18.75 | 1 puff | 6.84 | 24 |
| Tiotropium | Spiriva Respimat (SMI) | 12.92 | 2 puffs | 9.43 | 33 |
| Glycopyrronium bromide | Seebri Breezhaler (DPI) | 18.75 | 1 puff | 6.84 | 24 |
| Aclidinium bromide | Eklira Genuair (DPI) | 8.67 | 2 puffs | 6.33 | 22 |
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| BDP (extrafine)/ formoterol fumarate | Fostair NEXThaler1 | 7.41 | 2 to 4 puffs | 5.41 to 10.82 | 19 to 37 |
| Budesonide/ formoterol fumarate | Fobumix Easyhaler1 | 4.04 | 2 to 4 puffs | 2.95 to 5.90 | 10 |
| Budesonide/ formoterol fumarate | Symbicort Turbohaler 100/6 | 4.83 | 2 to 4 puffs | 3.53 to 7.05 | 12 to 24 |
| Budesonide/ formoterol fumarate | Symbicort Turbohaler 200/61 | 6.67 | 2 to 4 puffs | 4.87 to 9.74 | 17 to 34 |
| Budesonide/ formoterol fumarate | Symbicort Turbohaler 400/12 | 17.75 | 2 puffs | 12.78 | 44 |
| Budesonide/ formoterol fumarate | DuoResp Spiromax1 | 6.8 | 2 to 4 puffs | 4.96 to 9.93 | 17 to 34 |
| Fluticasone furoate/ vilanterol | Relvar Ellipta2 | 26 | 1 puff | 9.49 | 33 |
| Fluticasone propionate/ salmeterol | Fusacomb Easyhaler | 9.53 | 2 puffs | 6.96 | 24 |
| Fluticasone propionate/ salmeterol | Seretide Accuhaler | 15 | 2 puffs | 10.95 | 38 |
1 estimates do not include additional “prn” use as part of MART regimens; 2 first line for COPD
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| BDP (extrafine)/ formoterol fumarate | Luforbec 100/61 | 101.24 | 2 to 4 puffs | 73.90 to 147.81 | 255 to 510 |
| BDP (extrafine)/ formoterol fumarate | Luforbec 200/6 | 119.20 | 4 puffs | 174.03 | 600 |
| Fluticasone propionate/ salmeterol | AirFluSal MDI | 161 | 4 puffs | 235.06 | 811 |
| Fluticasone propionate/ salmeterol | Seretide Evohaler | 162 | 4 puffs | 236.52 | 816 |
1 estimates do not include additional “prn” use as part of MART regimens
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Indacaterol maleate/ glycopyrronium bromide | Ultibro Breezhaler (DPI) | 18.75 | 1 puff | 6.84 | 24 |
| Olodaterol / tiotropium bromide | Spiolto Respimat (SMI) | 12.92 | 2 puffs | 9.43 | 33 |
| Vilanterol / umeclidinium bromide | Anoro Ellipta (DPI) | 24.00 | 1 puff | 8.76 | 30 |
| Formoterol fumerate / aclidinium bromide | Duaklir Genuair (DPI) | 9.17 | 2 puffs | 6.69 | 23 |
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Fluticasone furoate/ umeclidinium bromide/ vilanterol trifenatate | Trelegy Ellipta | 26 | 1 puff | 9.49 | 33 |
| BDP (extrafine)/ formoterol fumarate dihydrate/ glycopyrronium bromide | Trimbow NEXThaler | 7.41 | 4 puffs | 10.82 | 37 |
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| BDP (extrafine)/ formoterol fumarate dihydrate/ glycopyrronium | Trimbow | 118.36 | 4 puffs | 172.81 | 596 |
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| Budesonide | Easyhaler Budesonide | 3.25 | 2 to 4 puffs | 2.37 to 4.75 | 8 to 16 |
| Budesonide | Pulmicort Turbohaler 100 micrograms | 7 | 2 to 4 puffs | 5.11 to 10.22 | 18 to 35 |
| Budesonide | Pulmicort Turbohaler 200 micrograms | 14 | 2 to 4 puffs | 10.22 to 20.44 | 35 to 70 |
| Budesonide | Pulmicort Turbohaler 400 micrograms | 34 | 2 to 4 puffs | 24.82 to 49.64 | 86 to 171 |
| Active ingredients | Device | CO2eq per puff (g) | Daily dose | Annual CO2eq (Kg) | Equivalent annual car miles |
| BDP extrafine | Kelhale (pMDI) | 86.64 | 2 to 8 puffs | 63.39 to 253.57 | 219 to 874 |
| BDP extrafine | Qvar (pMDI) Qvar Autohaler (BAI) Qvar Easi-breathe (BAI) | 101.75 | 2 to 8 puffs | 74.28 to 297.11 | 256 to 1,025 |
| BDP | Clenil Modulite (pMDI) | 81.90 | 2 to 8 puffs | 59.78 to 239.15 | 206 to 825 |
Used pMDI canisters still contain propellants; all used pMDI canisters should be returned to a pharmacy (or dispensing GP practice) to dispose of in an environmentally safe way.
Used inhalers should not be placed in general waste.
Used inhalers that are not returned to pharmacies but are placed in general waste for kerbside collection may end up in landfill, depending on local authority arrangements. As well as plastic pollution, this risks crushing or piercing the pMDI / BAI canister and releasing additional propellants into the atmosphere.
Inhalers should be placed in the pharmacy's pharmaceutical waste bins, which are incinerated (destroying the greenhouse gases); steel and aluminium may be recovered and recycled at some incinerators. Spacers cannot currently be recycled.
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