Drought and extreme heat, both exacerbated by climate change, have paved the way for excellent fire conditions in the western United States. As wildfire season heats up and smoke resurfaces as a serious health threat, experts are encouraging people to get ready for smoke. This includes stocking up on air purifiers and filters and, for those with lung disease most at risk, refilling medical devices such as inhalers.
But what if the devices used to treat the health impacts of climate change themselves contribute to the crisis?
Such is the case with metered-dose inhalers, which are prescribed to treat two of the most common respiratory diseases in the United States: asthma and chronic obstructive pulmonary disease. These inhalers use fluorocarbon aerosol propellants to deliver medication into the lungs. The propellants are greenhouse gases that can trap heat about 1,500 to 3,600 times as well as carbon dioxide for 100 years.
The good news is that there are other inhalers that are effective, competitive, and may contain the same active ingredients, but are not nearly as harmful to the climate. One type of these devices, known as dry powder inhalers, has significantly fewer emissions compared to traditional propellant devices. Replacing high-emission inhalers with this or another type of inhaler called soft-mist inhalers can lead to better outcomes for patients and the planet.
The contribution of metered dose inhalers to greenhouse gas emissions in the healthcare sector is significant. Researchers in Britain estimate they are responsible for 3 to 4 percent of the national health system’s emissions. And UK-based global pharmaceutical giant GSK said they are responsible for 45 percent of the company’s environmental footprint. Accordingly, efforts have been made in the UK and other European countries to reduce the environmental impact of asthma and COPD care from these inhalers.
Despite the fact that Americans used approximately 144 million metered-dose inhalers in 2020 — the greenhouse gas equivalent of half a million driving a year — the United States has generally ignored its contribution to global warming. As we phase out hydrofluorocarbons from other sectors of the US economy, the healthcare sector must do its part.
Sweden is using alternative dry powder inhalers at a higher rate than the United States, while achieving superior results in asthma care. And the Department of Veterans Affairs, which assesses drugs as it develops its national formulary, has contracted a drug of choice for dry powder asthma. Still, there’s a catch: Some inhaled medications aren’t yet available in the United States in dry powder or aren’t covered by insurance.
The US Department of Health and Human Services, which has pledged to reduce carbon emissions in the health sector, could help by encouraging the development and approval of affordable dry powder inhalers. Creating demand for non-propellant inhalers would persuade pharmaceutical companies to bring more of them to market. And insurers and hospitals motivated to influence climate change could send a signal by prioritizing low-warming inhalers over prescription drugs.
The United States could also improve health and reduce environmental impacts by using available inhalers more effectively. Asthma care lags behind other high-income countries’. Black and Native American populations in the United States are more likely than white Americans to have asthma and to experience a disproportionate burden of asthma-related health complications and deaths. The origins of these differences are related in part to structural racism, greater exposure to air pollution and heat (itself exacerbated by climate change), and reduced access to routine care, leading to fewer prescriptions for preventive drugs.
Research has shown that patients in the UK with poorly controlled asthma have an asthma-related carbon footprint approximately three times that of people with well-controlled asthma, likely due to the overuse of on propellant-based quick-reliever inhalers and more frequent emergency room visits during asthma attacks. To achieve better asthma control, more patients should be treated with inhalers to prevent flare-ups.
The climate and the world are changing. What challenges will the future bring and how should we respond to them?
As clinicians, we know that dry powder inhalers are not for everyone. These inhalers require patients to take deep breaths to aspirate the medication; the very young, the very old, and those with severe lung disease may struggle with it. Fortunately, metered dose inhalers with new propellants are in development that have virtually no or greatly reduced global warming. Such devices are urgently needed to provide patients with a full range of inhaler options and minimize emissions.
We recognize that talking about eco-friendly inhalers can bring back painful memories among health care providers who practiced in the 2000s. After the Montreal Protocol of 1987, older, ozone-depleting propellants were replaced by the current generation. The protocol not only protected the ozone layer, but also prevented a significant amount of global warming. However, pharmaceutical companies used this transition to put new versions of generic drugs under patent protection, and the cost of inhalers was expected to skyrocket.
This time we can and must do better. For now, patients should continue to use the inhalers they have been prescribed. But the United States needs a more robust selection of generic dry powder alternatives to reduce the impact on patients. And for those who continue to need metered-dose inhalers, policymakers and insurance companies need to protect patients from price increases.
The US health sector is a major contributor to climate change and is responsible for approximately 8.5 percent of domestic greenhouse gas emissions. As its fundamental mission is to promote health and well-being, it must seize every opportunity to reduce its impact on the climate.
Reducing emissions from inhalers is an opportunity to reduce carbon footprint while improving respiratory disease. The bushfire smoke is already blowing our way; let’s not add fuel to the fire.
Alexander S. Rabin is a clinical assistant professor of pulmonary and critical care medicine at the University of Michigan. Gregg L. Furie is a primary care physician and medical director for climate and sustainability at Brigham and Women’s Hospital.
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