© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/17151635231202980
The escalating threat of climate change presents a significant global health risk and demands immediate action from all sectors accountable for rising greenhouse gas (GHG) emissions.1 Canadian health care is responsible for 4.6% of national GHG emissions, with pharmaceuticals accounting for approximately one-quarter of this figure.2 Appropriate deprescribing can reduce health care emissions, and studies conducted in various countries reveal that most patients are open to the idea of reducing their medication intake if their doctors advise it.3 Thus, to substantially reduce their environmental impact and lessen the health harms of climate change, health care systems must modify existing practices by changing prescribing patterns, choosing lowcarbon alternatives and promoting safe pharmaceutical waste disposal.4
Pressurized metered-dose inhalers (pMDIs) are an important example of a medication type with a large environmental impact, due to the hydrofluorocarbon propellant used to deliver medication to the lungs.5 Over its entire lifecycle, a pMDI can release as much GHG as a 185 km journey from a standard gas-powered car.6 Several strategies are available to alleviate the GHG impact of pMDIs, and some simultaneously improve respiratory health. Patients requiring pMDIs can use a spacer to maximize the proper delivery of medication,7,8 thereby increasing therapeutic benefits and decreasing environmental impact. Another opportunity for mitigation is to return pMDIs to pharmacies for disposal and proper incineration of the propellant. When clinically appropriate, patients can switch to lower-carbon inhaler alternatives that do not require propellants, such as dry powder inhalers (DPIs) and soft mist inhalers (SMIs).5
Pharmacists who have direct and frequent patient contact play a critical role in engaging and educating patients about inhaler use. However, there remains a lack of literature about patient perspectives and knowledge on the environmental impact of inhalers.
To guide best practices for patient education on inhalers, this study surveyed perspective and knowledge around the environmental impacts of inhalers from outpatients in a British Columbia (BC) health region.
We conducted a cross-sectional survey of residents in the Fraser Health Authority (FHA), which serves the most populous health region in BC. We used Health Chat, an online community panel managed by FHA, to create an online mixed-methods survey investigating patients’ knowledge and perspectives on inhaler use. The inclusion criteria for the survey were individuals aged 16 and older who had a diagnosis of asthma or chronic obstructive pulmonary disease (COPD) and were regular inhaler users (defined as using at least 1 inhaler each year). The survey was approved for distribution by the FHA ethics committee as a quality improvement and evaluation initiative.
Prior to conducting the survey, 4 health care providers, including pharmacists and family physicians, pilot tested the survey questions and provided feedback, leading to necessary modifications. The final version of the survey comprised a total of 11 items (Appendix 1), using both mandatory closed and optional open-ended questions to obtain quantitative and qualitative data. The survey also included standardized items to gather participants’ sociodemographic characteristics. No incentives were offered to encourage participation; to ensure participants’ anonymity, no personal identifying information was collected.
Survey responses were analyzed using Microsoft Excel, and descriptive analyses were conducted to summarize respondents’ characteristics and survey responses.
Results
Of the 185 individuals who responded to the survey callout, 61 met the inclusion criteria and completed the survey. Ten participants provided free-text comments related to the study’s purpose. All age groups in 10-year intervals from 26 to 80 years old were represented in our survey response; however, most participants (70%) were older than 51 years (Table 1).
Most participants (61%) reported using pMDIs as their most frequent inhaler, followed by DPIs (34%), SMIs (3%) and nebulizers (1%) (Table 1). Only 30% of participants who required pMDIs reported using a spacer consistently. In addition, only 20% of participants reported that they returned their empty inhalers to the pharmacy, with most participants reporting that they disposed of their empty inhalers directly at home.
While 77% of patients reported receiving some level of inhaler training in the past year, 16% did not receive any training when provided with a new inhaler (Figure 1). Among those patients who received training, pharmacists, respiratory therapists or doctors were reported as the primary instructors.
When asked about the environmental impact of inhalers (Appendix 1, questions 7-9, 11), only 21% of patients were aware that some types of inhalers have a much higher carbon footprint than others (Figure 2). Most patients (59%) said it was important or very important to choose an inhaler with a low-carbon footprint, provided it offers the same therapeutic benefits. Participants identified more information as the most needed factor to support the switch to a low-carbon inhaler (35%), with advice from a prescriber (29%) or support from a pharmacist also being key (26%). Cost and convenience were cited as the main barriers to making the change.
One participant commented, “A lower carbon footprint is important. But not as important as an effective inhaler. For me, choosing a healthy life is more important than my carbon footprint.” Another individual added to the survey, “I would use a spacer/Aerochamber if that was covered by BC PharmaCare.”
Our survey study provides insights from the Canadian population into patient attitudes, knowledge and awareness of the environmental impact of pMDIs. Our results show that patients are willing to make the switch to lower-carbon alternatives, such as DPIs and SMIs, but most are uninformed of the environmental impact of pMDIs. Only 21% of patients surveyed were aware of the environmental impact of inhalers, emphasizing a need for education and teaching from health care workers across a patient’s disease management pathway.
Pharmacists can play a key role in reducing the climate impact of inhalers by providing education to patients on proper inhaler use and disposal. For example, only a minority of patients with pMDIs use a spacer (29% in our study). By educating patients about the benefits of using a spacer and how to use it properly, pharmacists can help ensure that patients receive the correct dose of medication while also maximizing the needed drug to its localized site of action. Proper disposal of inhalers is essential to incinerate any remaining propellant in each inhaler and thereby prevent these gases from leaking into the atmosphere.9 Educating patients about proper inhaler disposal helps ensure that these devices are recycled or disposed of in an environmentally responsible way.
Figure 1 Inhaler training
Figure 2 Patient awareness and perception of inhalers’ footprint
Most patients surveyed report using pMDIs as their main inhaler. This figure is in keeping with other Canadian studies examining inhaler prescription patterns10,11 but in contrast to prescribing patterns in European countries, where only 13% of inhalers prescribed in Sweden are pMDIs.12 There is a clear pathway to lessening the environmental impact of inhalers by switching patients to lower-carbon alternatives (i.e., DPIs and SMIs).
The cost and clinical efficacy of lower-carbon inhalers must be considered when engaging with patients on switching inhalers. Not only do pMDIs have a significant impact on the environment but they also pose several clinical issues. Inadequate inhaler technique is a common occurrence with pMDIs in outpatient settings.13 DPIs and SMIs have the potential for better medication delivery to the airways if used correctly, compared with pMDIs.14 Additionally, the absence of a dose counter on most pMDIs makes it difficult for patients to know when their inhaler is empty, resulting in improper disposal of nonempty inhalers or the use of empty inhalers.15 It is therefore critical that both pharmacists and prescribers provide clear and comprehensive information about the environmental and clinical differences between inhaler device types to appropriate patients.
This study has limitations. A major limitation is our small sample size (61 participants) and the lack of a priori sample size calculation. Our survey also has a potential selection bias toward patients who are more prone to answering surveys, which limits the generalizability of our findings to the wider population. Nevertheless, our findings highlight the importance of patient engagement by health care providers, such as pharmacists and family physicians, in driving change towards more sustainable use of inhalers.
While patient awareness of the climate impact of pMDIs is low, our study found that most patients are receptive to switching to lower-carbon inhaler alternatives, such as DPIs and SMIs. However, most patients require more education to understand the benefits and help overcome any perceived barriers, such as costs. Pharmacists and other health care providers can take an active role in engaging and educating patients on proper inhaler use and disposal. Through this approach, there is an opportunity to provide better respiratory care and lessen the increasing climate impact of health care. Future research needs to examine appropriate engagement and educational material that will both increase uptake of sustainable inhalers and improve patient-centred care.
From Fraser Health Authority (Quantz, Liang), Surrey, BC; and Lower Mainland Pharmacy Services (Wong), Surrey, BC. Contact kevin.liang@fraserhealth.ca.
Acknowledgments: We would like to thank Sergio Pastrana (Health Protection Quality Consultant, Fraser Health) and Tate Goodman for their input and contribution to the development of this research brief.
Author contributions: All authors contributed to the development of this article and approved the final version of the article.
Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
ORCID iD: Kevin Liang https://orcid.org/0000-0003-3470-8456
