Inhaled drugs and global warming: time to shift to dry powder inhalers
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3359 (Published 28 May 2013) Cite this as: BMJ 2013;346:f3359
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Hillman et al boldly claim that “the potential impact of climate change on respiratory health is widely (sic) appreciated.”1 However in the article supposedly supporting their submission we learn that:”Climate change will affect individuals with pre-existing respiratory disease, but the extent of the effect remains unclear.” 2
Does climate change make respiratory condition better or worse? Alas we do not know, unless one reads through the usual ‘supporting evidence’ about floods, hurricanes, earthquakes, famines, heat waves, mosquitos’ etc etc.
Confused? Then read on: ” Complete elimination of metered dose, hydro fluorocarbon driven inhalers is not yet feasible.”
In the following paragraph:” (we) urge policy makers to .....to phase out hydro fluorocarbon inhalers as soon as possible.”
Phasing out hydro fluorocarbon driven inhalers will make no difference whatsoever to either global warming or climate change (both terms used by the authors). The only country which has significantly decreased greenhouse gas emission is the U.S.A. This has been achieved through switching from coal to cheap gas (via shale extraction). The additional benefit is a cheaper domestic heat.
What we certainly know (based on countless articles, reliable statistics and experience) is that cold weather is detrimental to the health in general, and respiratory conditions in particular.
Perhaps the editors of the BMJ should listen less to the ‘Friends of the Earth’ (house insulation excepted) 3 and instead concentrate on being friends of the people, by making a case for affordable domestic energy.
1. Inhaled drugs and global warming: time to shift to dry powder inhalers
BMJ 2013;346:f3359
2. Climate change and respiratory disease: European Respiratory Society position statement.
Eur Respir J2009;34:295-302
3. The health impacts of cold homes and fuel poverty
BMJ 2011;342:d2807
Competing interests: No competing interests
The health risks from global climate change loom large[1] and actionable information regarding countermeasures is urgently needed.
Hillman et al [2] draw welcome attention to the role of hydrofluorocarbons (HFCs) in metered dose inhalers (MDIs) as an important greenhouse gas. They also point out the considerable variation in the proportion of inhalers prescribed that are MDIs between the UK and Sweden. Our own analysis using GP prescribing data for England and Wales has also shown considerable variation in practice (http://www.openprescribing.org/examples/hfc) the percentage of inhalers prescribed that are MDIs varied from 70% (NHS Lincolnshire West CCG) to 95% (NHS Islington CCG) over a six month period.
However, the proportion of UK green house gas emissions due to inhalers is small, and the cost of switching in carbon trading terms is high. Carbon dioxide is the dominant green house gas responsible for global warming. The amount of global warming a given type and amount of greenhouse gas causes is described with reference to the functionally equivalent concentration of carbon dioxide (CO2 e).
Total green house gas emissions in the UK in 2007 were 634.7 Mt CO2 e [3] and in 2012 emissions from MDIs in the UK were 1600 kt CO2 e (=1.6 Mt CO2 e).[4] On this basis MDI derived green house gas emissions are responsible for about 0.25% of total annual emissions.
The traded carbon price was £14 per tonne CO2 e in 2012.[5] Assuming an HFC content per inhaler of 17g and evaluating to 2025 using a discount rate of 3.5% the estimated cost of reducing HFC emissions from inhalers by 75% would be £174 per tonne CO2 e.[4] Of course what is good for the economy is not necessarily good and the argument for investing more in our environment and our health is not solely economic...
1. Health risks, present and future, from global climate change. McMichael T, Montgomery H, Costello A. BMJ 2012;344:e1359
2. Inhaled drugs and global warming: time to shift to dry powder inhalers. Hillman T, Mortimer F, Hopkinson NS.
BMJ 2013;346:f3359
3. http://unfccc.int/files/national_reports/annex_i_natcom/submitted_natcom... table 2.1 page 18
4. http://archive.defra.gov.uk/environment/quality/air/fgas/documents/fgas-... fig 8-1 page 55
5. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Competing interests: I am the CEO of Open Health Care UK (http://www.openhealthcare.org.org.uk), a software and analytics company. Open Prescribing (http://www.openprescribing.org) is a product of Open Health Care UK.
Re: Inhaled drugs and global warming: time to shift to dry powder inhalers
The purpose of our editorial was to bring the role of HFC propellants used in inhaler devices as a greenhouse gas to the attention of health professionals and to stimulate debate as to how these effects can be mitigated. It is certainly the case that other more conventional strategies to reduce CO2 emissions are important, including in areas of energy use and generation, as well as transport and the production of goods for consumption [1].
However, the use of HFC’s in medicine is particularly the concern and responsibility of health professionals and, we would argue, to a large extent could be eliminated.
Following (though not we imagine because of), our editorial, The White House has announced joint plans between China and the United States of America [2] to reduce the use of HFC’s, confirming our view that this is a significant area. This should also facilitate efforts to develop cost effective strategies for carbon reduction. Carbon values change over time in response to market forces. At present the costs of carbon emission seem set to rise [3] and a switch away from HFC inhalers will require alternative delivery devices to demonstrate that they are, in the broad sense, better value [4].
Dr Hudecek appears to question the impact of climate change on respiratory health. The potential health impacts of climate change are well described elsewhere [5] [6] and an increase in cardiorespiratory disease is anticipated, mediated by changes to ground level ozone and air quality.
Within respiratory medicine, the argument to move to treatments which are effective, have a lower carbon cost, and align with the priorities of patients is compelling.
We hope that our editorial serves as a stimulus to debate the wider impact of our actions within healthcare, and that clinical teams and clinicians will examine their efforts not only in terms of financial cost, but of their overall value. This will be achieved by reducing waste, both in terms of keeping to evidence based therapy to avoid under- and over-treatment, and in reducing the environmental impact of treatments by making low-carbon options available for patients.
1. http://www.ellenmacarthurfoundation.org/circular-economy/circular-economy (accessed 17th June 2013)
2. http://www.whitehouse.gov/the-press-office/2013/06/08/united-states-and-... (accessed 17th June 2013)
3. http://www.whitehouse.gov/sites/default/files/omb/inforeg/social_cost_of... (accessed 17th June 2013)
4. http://www.nejm.org/doi/full/10.1056/NEJMp1011024 (accessed 17th June 2013)
5. http://www.thelancet.com/series/health-and-climate-change (accessed 17th June 2013)
6. http://www.ipcc.ch/publications_and_data/ar4/wg2/en/ch8.html (accessed 17th June 2013)
Competing interests: No competing interests