Patients’ views and behaviours in relation to asthma inhalers use and their impact on environmental sustainability: a cross-sectional survey study
Authors: Herrera H , Charalambous M , Dean H , Youles D , Rutter P , Warren N 
Published: April 2024

Abstract

Introduction
Approximately 60 million inhalers are used annually in England, contributing 3% to the National Health Service (NHS) carbon footprint. Of these, 2 out of 3 are metered-dose inhalers (MDIs) containing greenhouse gas propellants.[1] The carbon footprint of an MDI device is around 500g CO2 equivalent, in contrast with the 20g CO2 equivalent of a dry powder inhaler (DPI).[2]
The NHS Long Term Plan introduced measures on environmental sustainability, leading to the National Institute of Health Care and Excellence (NICE) launching a ‘shared decision aid’ to promote the discussion of options for inhaler devices. This landmark policy step could be more effective if received with patient support and informed behaviours of patients with regard to inhalers. Research is therefore needed to identify patients’ views and behaviours on this matter.

Aim
To identify patients’ views and behaviours related to environmental sustainability aspects of their use of inhalers for the management of asthma.

Methods
An anonymous self-completion paper-based questionnaire was administered to patients with a clinical diagnosis of asthma. These were recruited opportunistically via 10 community pharmacies in the South of England during the month of February 2020. They were provided information about the study and invited to participate by pharmacy staff when collecting prescriptions. Participants had to be prescribed at least one MDI inhaler and not to be using a DPI, and report on the use, disposal and views regarding their environmental impact. Responses to the questionnaire were coded and analysed using descriptive statistics.

Results
A total of 149 surveys were completed by patients, of which 47% (n=70) were male and 53% (n=79) were female. The age range of respondents varied with the majority 45.6% being 18-29 years old, followed by 21.5% in the 60-69 years category. Of these, 30.2% (n=48) were aware of MDI inhalers having an impact on carbon footprint, and 53% (n=79) on plastic pollution. A majority (81%) of patients stated that they were involved or partially involved in their inhaler choice. Only 62% (n=92) said they would be willing to switch their MDI to a more environmentally friendly inhaler with equal effectiveness, 15.4% (n=23) reported they would not be willing to do so and 22.1% (n=33) were not sure. Unwanted inhalers were returned by 43% (n=64) of participants for appropriate disposal, with 55% (n=82) of respondents being unaware of this option. A majority (91%, n=136) of participants said they would like further information about their inhalers and their impact on the environment.

Conclusion
There is scope for a more environmentally friendly management of asthma and the use of inhalers. Healthcare professionals are involving patients in decision making when prescribing, and pharmacists could contribute to this when dispensing. Patients would welcome information on the impact of inhalers on the environment and further research could identify more precisely on what aspects, alongside barriers preventing a switch to more environmentally friendly options. A small sample size and geographical area were limitations of this study, which could be overcome by further researching issues identified in this survey.

References
1. Greener NHS: Improving health outcomes for respiratory patients while reducing carbon emissions. Available from: https://www.england.nhs.uk/greenernhs/whats-already-happening/improving-health-outcomes-for-respiratory-patients-while-reducing-carbon-emissions/
2. Wilkinson AJK, Braggins R 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).