Green Inhaler website

Frances Mortimer's picture

Author: 

Resource Description: 

This patient- and clinician-facing website gives guidance on choosing inhalers with lower environmental impact - something which is now included in the BTS asthma guidelines.

Source: 

Dr Alex Wilkinson

Publication date: 

September, 2019

Resource type: 

  • communications tool
  • information resource

Tags: 

Comments

prescribing

Mark Northcote's picture

thanks for this I'll be passing it on to my colleagues

Dangerous times talking of switch

Jane Scullion's picture

Incredible talking of switch this has become an emotive issue based on poor evidence and not accounting for production costs DPI higher impact due to production process. And PATIENT SAFETY.  0.1 % of footprint get real 

Interesting, but so complicated!

Mark Tyrrell's picture

This is my first post on this site, but as an environmental campaigner and Green GP this topic is so complicated to be sure we are doing the right thing!

So fine we end up with an end product the inhaler and then we can look at the environmental impact of the device, but what about the preceeding steps:

1/ Where did the raw resources come from?

2/ How were they produced?

3/ Where were they produced? (UK vs China vs EU?)

4/ Environmental transport costs of the raw products (e-lorries vs diesel?)

And so on. I would like to believe that there is a simple answer (as I would suspect so would 50% of the manufacturers!) but I suspect there isn't! We need to be really careful in making recommendations such as this.

It is similar for the paper cup vs plastic cup... Plastic is much thinner, easier to produce, weighs less etc so environmentally may have less impact than the heavier, thicker paper equivalent from trees found abroad!

Complicated, but not as bad as you might think

Alexander Wilkinson's picture

Multiple, comprehensive cradle to grave life cycle analyses have been done on metered dose inhalers and all conclude that between 95% and 98% of the carbon footprint of the inhaler comes from the propellant (listed below). These analyses all take into account the raw resource sourcing, production, transport etc. MDIs are unique in this regard because their propellant is such a powerful greenhouse gas; thousands of times more potent than CO2. The other factors that you mention pale into insignificance when considering carbon footprint.

There are other environmental impacts from MDI manufacture, such as ozone impact and mineral depletion. They are given careful consideration by the Jeswani and Azpagic paper. Differences between inhaler types are much more subtle with regard to these impacts compared to greenhouse gas release though.

Prioritising low global warming inhalers is part of NHS long term plan and a good practice point on 2019 BTS/SIGN asthma guidelines, so there is enough evidence to convince poliycy-makers.

Hope that helps.

Alex

Janson C, Henderson R, Löfdahl M, et al Carbon footprint impact of the choice of inhalers for asthma and COPD  Thorax Published Online First: 07 November 2019. doi: 10.1136/thoraxjnl-2019-213744 - see also

https://thorax.bmj.com/content/thoraxjnl/early/2019/11/07/thoraxjnl-2019-213744/DC1/embed/inline-supplementary-material-1.pdf?download=true

Life cycle environmental impacts of inhalers Jeswani, H. K. & Azapagic, A., 10 Nov 2019, In : Journal of Cleaner Production. 237, 117733.

Goulet B, Olson L, Mayer B. A Comparative Life Cycle Assessment between a Metered Dose Inhaler and Electric Nebulizer. Sustainability 2017; 9: 1725.

Reduced environmental impact of a reusable soft mist inhaler Michaela Hänsel, Thomas Bambach, Herbert Wachtel European Respiratory Journal 2018 52: PA1021; DOI: 10.1183/13993003.congress-2018.PA1021

Good questions about inhalers

Sarah Walpole's picture

Good questions about inhalers - and agree we need to take different factors into account and what is found to be most 'environmental' as well as most acceptable, e.g. taking into account labour conditions, etc. etc. will vary depending on what we choose to prioritise. Would be good if this was all transparent though and that's what i liked about the NICE inhaler tool - at least trying to make this more transparent for patients (broad brush) 

I'm involved in trying to run a QI project to move from MDI to DPI inhalers.


We wondered whether the Working group on reducing the climate change impacts of inhalers is still up and running and has any experience or recommendations that it can share. Does anyone know? Also, are there any plans for national work towards the target shifts - so that local project won't just overlap? - we want to make sure that we align with any national actions and build on them, don’t do something that will be done anyway!

 

Coordinating work on inhalers

James Smith's picture

Hi Sarah and others.

Sarah - It's great you are doing a QI project on inhaler switching. I'd be interested to hear more if you have time. My email is jns25@medschl.cam.ac.uk. 

I think we should definately look to encourage more work on switching at the clinical level and also push CCGs to update their guidance. I've a student who is going to look at variations in CCG asthma prescribing guidance. I'm also hoping to look at practice level switching with another student next year. I think there is definately an appetite for a guide for GPs on how to switch and what to switch to. 

One avenue which might be useful for promoting this work is an emerging new network of RCGP climate actions leads across the regions. Some regional faculties of RCGP already have leads. I'm just starting as the one for East Anglia and we are hoping that this might be picked up as something which takes off across the country given the RCGP's recent declaration of a climate emergency. 

In the meantime shall we just coordinate through this online network or do we need a specific group to link up in more depth on inhalers e.g. via video/teleconferences? As ever the challenge is who has capacity to organise something more proactive if that is what is needed. I'd be a keen participant but am hesitant about taking on an organisational/coordination role due to my other commitments. I am not currently part of the national working group organised by the SDU but think there could be value in a group pushing to speed up switching as it feels too slow at the moment to me. 

Thanks. James

 

 

 

 

Switching

Sian Williams's picture

It's good to hear about the regional climate change leads.  You might want to read the Primary Care Respiratory Society position on switching though: https://www.pcrs-uk.org/news/consider-wider-clinical-issues-switching-green-inhalers

Switching

James Smith's picture

Hi Sian, 

Thanks for sharing the PCRS response to our BMJ Open paper. 

Their response seems to make 2 main points:

1) don't just think of environment when switching, think of 'wider clinical considerations'. I agree and don't think we have argued otherwise.  My position is where clinically appropriate and in discussion with the patient we should switch to or start the lowest carbon footprint device. 

2) there are other wider environmental issues with respiratory care and we need to think about the whole pathway. Again I agree. I don't think anyone who supports more action on climate change thinks it requires just one action. It is apparent it requires change across all parts of healthcare and everything else. Switching and action across the pathways more generally are not in opposition but are both needed. 

So in short I agree with the main points made by the PCRS response. 

I do have some concerns with the PCRS response. 

Firstly I don't think the points above are in opposition to the paper's findings and a call for switching when clinically appropriate so it is a shame that the authors of the PCRS response feel the need to present the findings and then say 'But ....' or 'However....' as if they are. This seems to subtly (and perhaps inadvertantly) be underminding the findings and the idea of switching without actually criticising the content of the paper. 

Secondly the idea of 'blanket switching' is mentioned as something PCRS don't support but they don't define what they mean by blanket switching. If by blanket switching they mean switching all patients then they are attacking something not argued for in the paper. If by blanket switching they mean changing prescribing guidelines to include more DPI options and encourage their use where clinically appropriate and done in discussion with the patients e.g at their annual review with GP/nurse then I'd ask why don't they support this?  This feels like an critique based on something (switching all patients) not argued for in the paper. I am not sure why this was included. 

Thirdly in making the argument for work on pathways and wider environmental concerns of healthcare PCRS are on the one hand making a very reasonable point which I agree with but on the other in doing so so prominently in response to work on inhaler switching it also seems like they are saying 'don't pay attention to switching pay attention to other issues'. This concerns me in the context of the negative framing above as it appears to be using diversion as an approach to the question of switching rather than expressing a clear view on switching. A more constructive statement might have recognised the value of switching where clinically appropriate and also the need to address the wider issues in the whole pathway. 

Fourthly I am not clear why the response suggests this paper is 'food for thought' rather than a clear mandate for action. There is no acknowledgement that climate change is a time dependent problem and describing the findings as 'food for thought' seems to be supporting delay rather than an active response to the findings of our paper. 

In conclusion the PCRS raises a couple of good points which I agree with. However it don't know why it is framed in the way it is. I think they could have made the points they wanted to while also being much more positive in terms of recognising that where clinically appropriate, switching to lower carbon footprint devices is a good thing and it is a positive finding that this could be done in a way which didn't cost the NHS more money. 

Finally I just wanted to add that I am not familiar with PCRS so I went digging on the internet to understand more. I was interested to find that they are largely funded by the pharmaceutical industry with nearly half a million pounds of income from them in 2018, approx 2/3 of their income I think.(http://apps.charitycommission.gov.uk/Accounts/Ends17/0001098117_AC_20181231_E_C.PDF ) PCRS have a clear statement on pharmaceutical industry funding and a conflicts of interest statement on their website and I think this should mean that there weren't any direct vested industry interests involved the PCRS response to work on inhaler switching. I don't know if anyone on this forum is involved in PCRS or the pharma industry. I'd be interested to hear about whether there is any sense that the narrative about environmental issues and respiratory care could be influenced by the connections between the industry and PCRS. Shifting the focus from individual products to pathways for example is a narrative which I can see the industry promoting as it makes it less likely there will be rapid shifts away from specific products. Any insights would be appreciated. 

Sian - Thanks again for sharing this. I think it is really valuable to understand all of the above more. 

 

Switching

Sian Williams's picture

Thanks James. I don't know who from PCRS is on this either, but I'll email those I know and encourage them to join and respond to your points.   

Siân

Switching

Duncan Keeley's picture

Dear James

Thank you for your comment on Sian’s posting of a PCRS news item bringing your recent BMJ Open article to the attention of our membership. This brief comment has a weblink to a more detailed PCRS position paper on environmental issues in respiratory treatment which was issued before your article came out, and the comment should be read in conjunction with that document. 

We agree that the GWP of MDIs relative to DPIs and SMIs is an important issue that clinicians and patient should consider. We are involved in the work of the NHS Sustainability Unit’s work on this and we support moves to increase the proportion of UK respiratory treatment based on low GWP inhalers. The kind of ‘blanket switching” we think should be avoided is any group switching of prescriptions at population or practice level without individual discussions with patients. We appreciate that this was not advocated in your article, but such changes to prescribing practice have occurred in the past and would be particularly unwise for inhalers requiring different techniques of use. It is important to consider the needs of those patient groups for whom MDIs are the best treatment method. We also need to set this work in a wider context, both in respect of the multiple ways in which the environmental impact of respiratory management could ( and should ) be improved and in the more widespread changes in behaviour needed to meaningfully address the national carbon footprint and climate change. We must be careful to avoid respiratory patients feeling a disproportionate sense of responsibility.  Again we appreciate that your article did not argue otherwise – but our position paper was developed to address the broader policy context. 

PCRS is a multiprofessional organisation committed to improving standards of respiratory care. You are right to say that – in common with most primary care special interest groups -we have substantial support from a wide range of pharmaceutical companies. We are a registered charity, our website carries information about our funding and conflict of interest declarations for committee members. The views we express on this and other issues seek always to be independent of pharmaceutical company interests – which in this matter are as complex and multifaceted as the issue itself. 

The BMJ Open paper to which you contributed provides a valuable analysis of the potential prescribing cost implications of wider use of low GWP inhalers and we are sorry that you felt that our news item implied disagreement with its findings – this was not intended.

Best wishes

Dr Duncan Keeley

Executive Committee PCRS

Switching

James Smith's picture

Thank you Duncan for your comments. It is really useful to understand PCRS and its position on these issues. It sounds like we agree on the vast majority of this, and certainly on the importance of tailoring inhaler choice to individual patients and doing this in discussion with them. Many thanks. James

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