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Cien Saude Colet 2025; 30:e06132024
DOI: 10.1590/1413-81232025309.06132024EN
Ciência & Saúde Coletiva
cienciaesaudecoletiva.com.br
ISSN 1413-8123. v.30, n.9
Abstract e aim is to calculate the carbon footprint of metered-dose inhalers used for asthma and chronic obstruc-
tive pulmonary disease management, distributed by the Brazilian National Health Service in Brazil and in the city
of Porto Alegre, Brazil, in the year 2019. Data regarding the dispensation of salbutamol and beclomethasone were
obtained upon request from the Ministry of Health. e dispensations were multiplied by the proportional carbon
footprint of each device. e prescription of the metered-dose inhalers resulted in between 24,889,141 and 60,878,728
tons of CO2-eq released into the atmosphere in Brazil (equivalent to traveling 23 to 57 million times the north-to-
-south distance of Brazil in a standard gasoline car); and between 459,830 and 1,151,008 tons of CO2-eq in the city
of Porto Alegre. e study demonstrated the substantial amount of GreenHouse Gas emissions associated with these
devices in Brazil. e substitution with dry powder inhalers or So mist inhalers in appropriate situations would
prevent signicant environmental harm, while also providing clinical benets to patients, as they are currently the
rst-line choice recommended by clinical guidelines for the treatment of respiratory diseases.
Key words Asthma, Beclomethasone, Albuterol, Carbon footprint, Climate change
Carbon footprint of inhalers in Brazil and Porto Alegre:
impacts and alternatives
1 Gerência de Atenção
Primária à Saúde, Grupo
Hospitalar Conceição. Av.
Francisco Trein 596, Bairro
Cristo Redentor. 91350-200
Porto Alegre RS Brasil.
paola.amia@gmail.com
2 Programa de Pós-
Graduação de Educação
em Ciências, Universidade
Federal do Rio Grande do
Sul. Porto Alegre RS Brasil.
3 Departamento de Saúde
Pública, Faculdade de
Medicina de Botucatu,
Universidade Estadual
Paulista. Botucatu SP Brasil.
Paola Flamia Simões https://orcid.org/0009-0003-7603-3212 1; amires Pereira Braga da Silva https://orcid.org/0009-0005-8151-8761 1;
Enrique Falceto de Barros https://orcid.org/0000-0002-2367-7001 2; Karina Pavão Patrício https://orcid.org/0000-0003-2112-5956 3;
Rafaela Brugalli Zandavalli https://orcid.org/0000-0002-3636-5808 1
2
Simões PF et al.
Introduction
Climate change (CC) is considered the greatest
threat and, consequently, the greatest opportu-
nity for public health in the 21st century1,2. It
stems from the increasing anthropogenic emis-
sion of greenhouse gases (GHG) into the atmo-
sphere3-6. is eect has impacted humanity
in various ways, including the rise of extreme
events such as heatwaves, droughts, wildres,
oods, and cyclones, which intensify socio-en-
vironmental inequalities and health inequities5.
Each year, e Lancet Countdown publishes
data from 44 indicators on the impacts of CC
on health, based on studies by more than 120
scientists world6. Among the diseases related
to CC are the rise of waterborne, vector-borne,
and other zoonotic diseases (such as dengue
and malaria), cardiorespiratory conditions, heat
stress, malnutrition, obesity, non-communica-
ble chronic diseases, and various mental health
disorders5-7. ese and other data demonstrate
the delayed and inconsistent response from
countries, providing “a clear imperative for ac-
celerated action that places the health of people
and the planet above other agendas”6.
Although healthcare services attend to pop-
ulations aected by CC impacts, paradoxically,
they also contribute to worsening this scenario
through the environmental impact and signif-
icant carbon footprint (CF) they generate. If
all health systems in the world were united as
a single country, they would rank h global-
ly in GHG emissions, as they are responsible
for 4.4% of total global emissions8, equivalent
to 514 coal-red power plants9. Moreover, the
healthcare system plays an essential role in set-
ting an example for society8.
e medicines are part of the CF of health-
care services, with the largest component of the
CF for primary healthcare (PHC) profession-
als being their prescriptions. e most signi-
cant contribution comes from bronchodilators
and inhaled corticosteroids (ICS) in the form
of pressurized metered-dose inhalers (pMDI),
used in the treatment of asthma and chronic ob-
structive pulmonary disease (COPD). ese are
widely available in the Brazilian Unied Health
System (SUS), both in the Popular Pharmacies
and in the pharmacies from Primary care /
Family Health Strategy10-12. In England, for in-
stance, pMDI inhalers are responsible for 3%
of the total carbon footprint of the healthcare
system12,13. ey have an extremely high global
warming potential (GWP) and are used at a rate
that could be optimized, making them a critical
point of concern14.
e pMDIs contain a propellant gas with a
GWP approximately 1,300 times greater than
the more widely known greenhouse gas, carbon
dioxide (CO2). is greenhouse gas is called
norurane (HFA-134a), which belongs to the
hydrouoroalkanes (HFA) family, a subtype of
uorinated gases (F-gases). To illustrate, 100
pus of a Salbutamol pMDI are equivalent to
driving a car for approximately 290 km in terms
of GHG emissions15.
e F-gases were introduced into inhal-
er devices (ID) to replace chlorouorocarbon
(CFC) gases, which deplete the ozone layer. e
Montreal Protocol in 1986 banned CFC gases.
However, in 2016, an amendment was added to
the protocol: the “Kigali Amendment,” which
encourages nations to reduce F-gas emissions
by 85% between 2019 and 2036 for developed
countries and by 80% between 2024 and 2045
for developing countries. Globally, if all coun-
tries met the F-gas reduction targets, this would
reduce the global temperature rise by 0.5°C
during this century, substantially decreasing the
impacts of CC16. ere are alternatives to pM-
DIs: dry powder inhalers (DPIs) and so mist
inhalers (SMIs). Both do not contain a pro-
pellant gas and are therefore more sustainable;
however, they are less frequently prescribed.
Although the perspective holds that it is im-
possible to think about human health without
considering the health of the planet on which
humans depend3, it would be problematic for
healthcare professionals to opt for prescribing a
more sustainable medication if it did not oer
the greatest clinical benet. However, the lat-
est update from the main guideline for asthma
treatment, GINA (Global Initiative for Asth-
ma)17, highlights as rst-line treatment medi-
cations available in DPIs, such as Formoterol
+ Budesonide (step 1 in asthma), which reduce
hospitalizations and severe disease exacerba-
tions, beneting both patients and the planet18.
Additionally, the most recommended treat-
ments for COPD, such as long-acting beta-ag-
onists (LABAs) and long-acting muscarinic
antagonists (LAMAs), are also available in DPI
forms19.
To build a more sustainable and healthier
healthcare system, the rst step is to identify
where the GHG emissions are coming from and
quantify them20. However, in Brazil, data in the
literature quantifying this environmental im-
pact related to healthcare is scarce. is study
oers an unprecedented contribution to under-
standing the carbon footprint of pMDI inhal-
ers dispensed by the SUS in Brazil as a whole
and specically in Porto Alegre (RS). To date,
3
Ciência & Saúde Coletiva, 30(9):1-14, 2025
no studies have investigated this data on such
a scale.
When the environmental, health, and eco-
nomic costs related to medications are not
well known and quantied, it can be dicult
for public policy decisions to determine which
medications oer the best cost-benet for the
population and are best suited for inclusion in
the basket of medicines provided by the SUS.
Furthermore, it is essential nowadays for in-
stitutions to incorporate ESG (Environmental,
Social, and Governance) practices to promote
health21.
e United Nations (UN) is concerned
about the climate crisis and calls for the rap-
id transformation of societies22. At the same
time, more than two-thirds of the global health
workforce – 45 million doctors and healthcare
professionals worldwide – signed an open let-
ter, urging national and international leaders at
the Conference of the Parties (COP) to intensi-
fy climate action plans. Healthcare profession-
als stated that they are already dealing with the
health damages caused by CC in their care for
the population and, therefore, advocate for cli-
mate action22,23.
is research aims to estimate the carbon
footprint of inhalers for asthma and COPD,
specically pressurized metered-dose inhalers
(pMDIs), dispensed by the Popular Pharmacy
Program and the SUS as a whole (excluding the
Popular Pharmacy) in Brazil and, specically, in
Porto Alegre (POA - RS), in the year 2019.
Methods
Study design
is is an ecological study. e primary
study location, Brazil, was chosen to represent
the entire country. e secondary study loca-
tion, the city of Porto Alegre, was selected for
convenience. e year 2019 was chosen as it is
the year immediately preceding the COVID-19
pandemic, during which the prescription of
medications for asthma and COPD occurred
under normal circumstances.
e sample consisted of the total amount of
salbutamol sulfate and beclometasone dipropi-
onate pMDIs with recorded dispensation in the
SUS network as a whole and the Popular Phar-
macy Program, in both Brazil and Porto Alegre,
in the year 2019.
is study was approved by the Ethics Com-
mittee of the Nossa Senhora da Conceição Hos-
pital – Conceição Hospital Group under the
number 70361623.5.0000.5530.
Estimated carbon footprint calculation
e carbon footprint (CF) of inhaler devices
(IDs) was calculated by multiplying the mass of
the greenhouse gas (GHG) by its global warming
potential (GWP) – a measure of the heating ca-
pacity of a gas relative to carbon dioxide (CO2).
e result was expressed in CO2 equivalent
(CO2-eq), a term used to estimate the amount
of CO2 mass that would be needed to cause the
same level of warming over a given period as the
GHG in question. CO2-equivalent emissions
provide a common scale for comparing dier-
ent GHG emissions, though it does not imply an
equivalence in the corresponding climate change
impact, since the gases have dierent atmospher-
ic lifetimes (CO2 and HFA remain for dierent
lengths of time, but both for a few centuries)
16,
24
. For example, the GWP of HFA-134a is 1,300,
meaning that 1 ton of HFA-134a warms the atmo-
sphere 1,300 times more than 1 ton of CO2. e
lifetime of this gas in the atmosphere is approx-
imately 14 years, meaning that the heat would
remain trapped in the atmosphere for 14 years
25
.
For a more comprehensive analysis of the
CF of a product, beyond assessing the quantity
of GHGs present and their respective GWP, all
emissions from the product’s production chain
(such as the CO2 emitted by the industry during
manufacturing and transportation to end con-
sumers) could be evaluated. However, a life-cy-
cle analysis is complex and beyond the scope
of this study. erefore, this research focused
solely on the CF related to the GHG present in
pMDI-type IDs, calculating the CO2-eq.
e mass of the HFA-134a gas in inhaler
devices (IDs) can vary depending on the man-
ufacturer and the presence or absence of alco-
hol in their composition, but this information
is not publicly available from the various lab-
oratories supplying the SUS. erefore, it was
necessary to explore the literature to determine
the average quantity (mass) of HFA-134a gas in
each ID, and thus estimate its carbon footprint
(CF). Based on studies that analyzed IDs in vi-
tro, comparing their full and empty states to es-
timate the amount (mass) of HFA-134a gas, it is
known that devices containing alcohol require
less HFA-134a propellant gas (categorized as
small-volume devices – 6.68–8.5g), whereas de-
vices without alcohol contain more HFA-134a
(categorized as large-volume devices – 17.32–
19.8g), and the latter have a higher CF18.
4
Simões PF et al.
e CF estimate for both large-volume
(without alcohol) and small-volume (with al-
cohol) devices was calculated by multiplying
the mass of the HFA-134a gas by its GWP, as
published in the Fih Assessment Report of the
IPCC.
Data acquisition for medication
dispensation
Data on the quantity of Salbutamol Sulfate
and Beclometasone Dipropionate devices dis-
pensed within the SUS network (including the
Popular Pharmacy Program and the SUS as a
whole) in Brazil and Porto Alegre in 2019 were
requested through the integrated platform for
citizen services and access to information of the
federal government (Fala.BR portal) 27, in accor-
dance with the Data Transparency Law. Infor-
mation regarding dispensations from the Pop-
ular Pharmacy Program was made available on
May 23, 2022, by the Coordination of the Pop-
ular Pharmacy Program of the Department of
Pharmaceutical Assistance and Strategic Inputs
and the General Coordination of Basic Pharma-
ceutical Assistance (CGAFB/DAF/SCTIE/MS),
both linked to the Ministry of Health (MS)/
Department of Pharmaceutical Assistance and
Strategic Inputs/Secretariat of Science, Technol-
ogy, Innovation, and Strategic Health Inputs.
On August 12, 2022, data regarding dispen-
sations from the “SUS as a whole” network in
Brazil and Porto Alegre for the year 2019 were
made available. is data was extracted by these
agencies from the National Database of Phar-
maceutical Assistance Actions and Services
(BNAFAR) and provided to the researchers,
presented in the Supplementary Materials (Ap-
pendices A and B, available at Ciência & Saúde
Coletiva Dataverse). Dispensation data catego-
rized as “SUS as a whole” refers to the records of
dispensations that predominantly occur within
SUS pharmacies that assist primary healthcare,
excluding medications from the Popular Phar-
macy Program, and there may be an underes-
timation of records from some municipalities.
Data analysis
e data provided by the Ministry of Health
(MS) referred to the total dispensations of in-
haler devices (IDs) for each medication (Sal-
butamol 100 mcg; Beclometasone 250 mcg;
Beclometasone 200 mcg; and Beclometasone
50 mcg), not specifying which laboratory or
whether they are large or small volume.
e total amount of Salbutamol and Be-
clomethasone dispensed by SUS and Farmácia
Popular in Brazil and in POA (RS) was added
up separately. To estimate the carbon footprint
(CF) of Salbutamol pMDIs in Brazil and Porto
Alegre, the CF of each large-volume Salbutamol
device was rst multiplied by the total dispensa-
tions of Salbutamol across the SUS and the Pop-
ular Pharmacy in Brazil and separately in Porto
Alegre. Secondly, the CF of each small-volume
Salbutamol device was multiplied by the same
total dispensations, considering, alternatively to
the previous hypothesis, that all Salbutamol dis-
pensations were of small-volume subtype. e
same process was repeated for Beclometasone.
e various formulations of Beclometasone (50
mcg, 200 mcg, and 250 mcg) refer to dierent
amounts of medication in the device, not to the
quantity of HFA-134a; thus, for the CF calcula-
tion, they can be summed as equivalent. Aer
this, the CF of the Salbutamol and Beclometa-
sone devices was summed, hypothetically con-
sidering them all to be large-volume, resulting
in the CF of dispensations of pMDIs if all were
large-volume. Sequentially, the CF of Salbu-
tamol and Beclometasone devices was summed
again, considering all to be small-volume. With-
in the interval between these values lies the data
sought in this study: the CF of pMDI-type IDs
provided by the SUS and the Popular Pharmacy
Program in Brazil and Porto Alegre in 2019.
Calculation of carbon footprint
equivalences
To calculate the carbon footprint equiva-
lences of the inhaler devices (IDs) used for the
treatment of asthma and COPD, specically
pMDIs (Salbutamol and Beclometasone) in
Brazil, for both small and large volumes, the
following factors were analyzed: (a) greenhouse
gas emissions, (b) CO2 emissions, (c) avoidance
of greenhouse gas emissions, and (d) carbon se-
questration.
An online calculator from the United States
was utilized for this purpose. e measures
from the calculator were adapted to equivalents
used in Brazil (e.g., converting miles to kilome-
ters). To calculate the distance between the most
extreme points in Brazil, from North (Cabraí)
to South (Chuí), a straight-line distance of
4,378.41 km was considered.
5
Ciência & Saúde Coletiva, 30(9):1-14, 2025
Cost analysis
To estimate the nancial cost of replacing
pMDIs with DPIs, Salbutamol and Beclometa-
sone were chosen as pMDIs, while Formoterol
+ Budesonide was selected as the DPI, focusing
on asthma treatment. e prices that the SUS
can pay generally, considering the lowest and
highest possible prices per dose, are as follows:
Beclometasone 250 mcg: R$ 0.16 - 0.22 per
dose (pu) (with higher or lower prices for dos-
es of Beclometasone 50 mcg or 200 mcg).
Salbutamol 100 mcg: R$ 0.083 - 0.11 per
dose (pu).
Formoterol + Budesonide: R$ 1.05 - 1.83
per dose (capsule) (averaging the lowest and
highest prices based on doses of 6 mcg + 200
mcg or 12 mcg + 400 mcg).
e absolute values per bottle were extract-
ed from the maximum selling price table to the
government (PMVG) provided by the National
Health Surveillance Agency (ANVISA)29 and
divided by the number of doses in each bottle.
e number of doses used for asthma treat-
ment varies greatly based on age, disease stage,
and level of control. erefore, it was decided to
consider that, on average, an individual uses 181
doses (pus) of Salbutamol and 60 doses (pus)
of Beclometasone per month, which could be
substituted with 60 doses (capsules) of Formo-
terol + Budesonide. ese monthly doses were
estimated because Formoterol + Budesonide is
commonly used at a dose of one capsule twice
daily (totaling 60 doses/month). Beclometasone
is usually used at a dose of one pu twice dai-
ly (it can be used from zero to four doses per
application twice a day), while Salbutamol is
used on a non-xed basis (typically four pus
per application as needed, up to every four
hours). e additional amount of Salbutamol
prescribed compared to Beclometasone follows
the dispensing ratio of these medications by the
SUS overall for the year found in this research:
3.02 times more Salbutamol is dispensed than
Beclometasone.
To estimate the reduction in hospitalization
costs due to asthma resulting from the switch to
DPIs, a 37% reduction rate (the rate of reduced
hospitalizations associated with the substitution
of Salbutamol and Beclometasone with Formo-
terol + Budesonide) 17 was applied to the total
cost of asthma hospitalizations in 2013, which
is the most recent data in the literature from a
study analyzing the DATASUS database30.
Results
e calculations of the quantities of units and
their corresponding carbon footprints were
performed according to the medication (Salbu-
tamol or Beclometasone), geographic location,
dispensing pharmacy, and considering them as
all being high/large or low/small volume HFA-
134a. It is observed that the highest dispensing
occurs at the Farmácia Popular, and Salbutamol
consequently has the highest carbon footprint
compared to Beclometasone, both in Brazil and
in Porto Alegre (POA), proportionally (Table 1).
e prescription of pMDI inhalers within
the SUS in 2019 resulted in CO2-eq emissions
ranging from 24,889,141 to 60,878,728 tons
across the entire Brazilian territory (Table 2;
values considering whether all devices were
of low/small or high/large-volume), which is
equivalent to traveling between 23 to 57 million
times the distance from the northernmost to the
southernmost point of Brazil in a convention-
al gasoline vehicle, among other comparisons
with emission or carbon sink measures (Figure
1 and Supplementary Table Annex C, available
at Ciência & Saúde Coletiva Dataverse).
Additionally, in Porto Alegre, the prescrip-
tion of these devices resulted in emissions be-
tween 459,830 and 1,151,008 tons (Table 2),
corresponding to traveling the distance between
the north and south of Brazil between 433 thou-
sand and 1 million times in a conventional gas-
oline vehicle (Figure 2 and Supplementary Table
Annex C, available at Ciência & Saúde Coletiva
Dataverse).
Regarding the estimated cost of replacing
all the pMDIs dispensed annually by the SUS
considering all of Brazil (R$ 45,225,797,274.60
to R$ 60,813,582,654.00) with DPIs (Formoterol
+ Budesonide), this would increase by 155.86%
to 231.62%, totaling R$ 115,642,641,030.00 to
R$ 201,671,137,886.11, always considering the
lowest and highest values for each medication.
On the other hand, the total cost of the
129,728 hospitalizations for asthma across all
age groups, excluding indirect costs (loss of pro-
ductivity due to absences from work and school
and premature mortality), in the year 2013, was
R$ 69,566,007.37 (an average of R$ 519.57 per
hospitalization) 30. Conversely, considering the
hospitalization reduction rate associated with
the daily use of Beclometasone combined with
rescue Salbutamol replaced by the use of For-
moterol + Budesonide available in DPI, which is
6
Simões PF et al.
37%17,31, it can be estimated that it would reduce
R$ 25,739,422.00 in hospitalization costs for the
health system annually.
Discussion
It is estimated that the prescription of pMDIs for
the treatment of respiratory conditions such as
asthma and COPD in the SUS in 2019 resulted
in approximately 24,889 - 60,878 kilotonnes (kt)
of CO2 equivalent released into the atmosphere
across Brazil and 459 – 1,151 kt CO2eq specif-
ically in Porto Alegre. is value reects a pre-
scribing pattern related to the use of Salbutamol
(available in the SUS in the form of pMDI) as a
rst-choice treatment for rapid symptom relief/
rescue, and Beclometasone as the rst option
for maintenance treatment (also more available
in the SUS in the form of pMDI).
In comparison, domestic emissions in 2019
were: 1,300 kt CO2eq in the United Kingdom,
520 kt CO2eq in France, and 450 kt CO2eq in
Germany32. In Europe, the proportion of pM-
DIs among inhalers is approximately 40%-50%,
about 70% in the United Kingdom, 22.6% in Ja-
pan, and 13% in Sweden, with the latter being
examples of countries that already have a pre-
dominance of other, more sustainable types of
inhalers32. e proportion of pMDIs in Brazil’s
SUS is likely much higher than in these coun-
tries, and the number of medications dispensed
Table 1. Total quantities dispensed of salbutamol 100 mcg and beclometasone (50 mcg, 200 mcg, 250 mcg, and 400
mcg pMDI aerosol) by Farmácia Popular and SUS in 2019 in Brazil and Porto Alegre.
Medication Dispensing
location
Dispensing
department
Quantity
dispensed
(inhalers)
Total
quantity
dispensed
by location
(inhalers)
Carbon
footprint
(kg CO2-eq)
Small volume**
Carbon
footprint
(kg CO2-eq)
Large volume*
Salbutamol
aerosol
(pMDI)
Brazil Farmácia
Popular
1.662.341.600 1,662,895,271 16,628,952,710 46,561,067,588
SUS 553,671
Porto
Alegre
Farmácia
Popular
33,069,800 33,184,567 331,845,670 929,167,876
SUS 114,767
Beclometasone
aerosol
(pMDI)
Brazil Farmácia
Popular
549,249,500 550,679,243 8,260,188,645 14,317,660,318
SUS 1,429,743
Porto
Alegre
Farmácia
Popular
8,492,800 8,532,307 127,984,605 221,839,982
SUS 39,507
* Carbon footprint of large volume devices: salbutamol = 28 kg CO2-eq/inhaler. Beclometasone = 26 kg CO2-eq/inhaler. **
Carbon footprint of small volume devices: Salbutamol = 10 kg de CO2-eq/inhaler. Beclometasone = 15 kg de CO2-eq/inhaler.
Source: Authors.
Table 2. Final result of the estimated Carbon Footprint of inhalation devices used for the treatment of asthma
and COPD of the pMDI type (salbutamol and beclometasone) dispensed by the Popular Pharmacy and SUS
network in Brazil and in Porto Alegre in 2019.
Description Carbon footprint – considering all low
volume inhalers (kg of CO2-eq)
Carbon footprint – considering all high
volume inhalers (kg of CO2-eq)
Total Brazil 24,889,141,355 60,878,727,906
Total Porto Alegre 459,830,275 1,151,007,858
* Carbon footprint of large volume devices: salbutamol = 28 kg CO2-eq/inhaler. Beclometasone = 26 kg CO2-eq/inhaler.
** Carbon footprint of small volume devices: salbutamol = 10 kg de CO2-eq/inhaler. Beclometasone = 15 kg de CO2-eq/inhaler.
Source: Authors.
7
Ciência & Saúde Coletiva, 30(9):1-14, 2025
is proportionally higher due to Brazil’s larger
population, which would justify the country’s
pMDI inhalers having a signicantly higher
carbon footprint compared to other countries.
In regard to the experience of other coun-
tries on the subject, it is observed that emissions
are oen avoidable by switching to less polluting
devices33. Comparing the proportion of pMDI
prescriptions in England (70%) to Sweden
(13%), it is estimated that if England adopted
the Swedish prescription standard (favoring
DPIs whenever appropriate for the patient), it
Figure 1. Infographic: equivalences of the carbon footprints of inhalation devices used for the treatment of
asthma and COPD of the pMDI type (salbutamol and beclometasone) in Brazil, of low and high volume,
respectively, in relation to the quantity of greenhouse gas emissions, CO2 emissions, avoidance of greenhouse
gas emissions, and carbon sequestration.
Source: Authors.
8
Simões PF et al.
would avoid the emission of 422 kg CO2 equiv-
alent per patient per year34. Comparatively, the
individual action of switching a pMDI for a
DPI could prevent 150 to 400 kg CO2 equiva-
lent from being released into the atmosphere
annually, which is environmentally equivalent
to that individual adopting a recycling habit,
implementing selective waste collection, or cut-
ting down on red meat consumption during the
treatment period35. Furthermore, the English
healthcare system (NHS) set a goal that by 2022,
at least 50% of prescribed inhalers would be of
low global warming potential16, with the aim of
achieving zero emissions by 204536. A coalition
Figure 2. Infographic: equivalences of the carbon footprints of inhalation devices used for the treatment of As-
thma and COPD of the pMDI type (salbutamol and beclometasone) in Porto Alegre, of low and high volume,
respectively, in relation to the quantity of greenhouse gas emissions, CO2 emissions, avoidance of greenhouse gas
emissions, and carbon sequestration.
Source: Authors.
9
Ciência & Saúde Coletiva, 30(9):1-14, 2025
of health institutions has followed their com-
mitment to the goal of “zero emissions” in Brazil
through the Healthy Hospitals Project and the
Global Health Without Harm Network37. Seven
health institutions have joined the challenge,
aiming to reduce greenhouse gas emissions by
50% by 2030 and achieve zero emissions by
205038.
Beyond the carbon footprint, cost is a con-
cern in this regard, as DPIs are more expensive
compared to pMDIs. Regarding the increased
cost for transitioning from pMDIs to DPIs,
it should be considered that Formoterol +
Budesonide, available in DPIs, reduce hospital
admission rates by 37% compared to the daily
use of Beclometasone combined with rescue
Salbutamol17,31, which would generate a savings
of R$ 25,739,422.00 for the healthcare system
in one year. Additional savings should also be
considered from indirect costs associated with
reduced hospitalizations, such as decreased
productivity due to absenteeism from work
and school, and premature mortality. It should
also be noted that there will likely be a reduc-
tion in outpatient consultations and the use of
oral corticosteroids since patients achieve bet-
ter disease control with the use of Formoterol +
Budesonide, which is the rst choice in asthma
treatment and reduces the risk of severe exac-
erbations19.
Other countries have made this cost estima-
tion for the replacement of pMDIs to DPIs by
switching exactly the same medication from its
pMDI format to DPI; however, this is not the
reality of the medications available in the Bra-
zilian SUS. us, the United Kingdom, which
has a 70% prescription rate for pMDIs, found
that switching 10% of its pMDI medications
to DPIs could result in either a reduction (£8.2
million per year) or an increase (£12.7 million
per year) in costs, depending on the brand of
the medication used, with some options being
cheaper than others on the market18. In Japan, it
is estimated that a 10% reduction in pMDI pre-
scriptions among the population aged 14 to 74,
which is already low (22.6%), would prevent the
emission of 12.4 kt CO2 equivalent and would
result in a 1.4% increase in costs due to the sub-
stitution of pMDIs for DPIs32.
Furthermore, for an adequate cost-eective-
ness analysis, other aspects must also be consid-
ered, such as the utilization/waste of medication
related to inhalation technique and the impacts
of chronic diseases on long-term economics,
making it important to have a broader perspec-
tive within public health18. Studies show that
65% to 72% of patients make errors when using
inhalers, and in 30% to 32% of cases, these er-
rors are signicant enough to impair treatment
eectiveness39. Comparing the error rates in
inhalation technique among dierent devices,
96% of patients can perform the steps correctly
when using DPIs compared to only 24% in the
pMDI group40.
Some issues are identied regarding the use
of pMDIs: the inhalation technique requires
coordination between the activation of the
medication release and simultaneous slow and
prolonged inhalation, and some patients do not
inhale long enough aer activating the device,
leading to oropharyngeal deposition of the drug
and resulting in inecient administration of the
medication. Furthermore, those containing in-
haled corticosteroids (ICS) can lead to the pro-
liferation of fungi and oral candidiasis. It is esti-
mated that, in most patients, only about 10% of
the dose reaches the lungs, while 80% remains
in the oropharynx, although this varies depend-
ing on the preparation and application device41.
Additionally, in the most common pMDIs
dispensed by the SUS, it is not possible to vi-
sualize how many doses remain in the device,
which can cause some patients to continue us-
ing the device despite the absence of medica-
tion, or to discard the inhaler with unused re-
maining doses, resulting in waste42-44. One study
found an alarming statistic revealing that 40%
of patients believe they are using their asthma
medication when they are actually activating
an empty pMDI canister, which is very relevant
to health44. Regarding DPIs, it is important to
note that adequate lung capacity is needed to
generate sucient inspiratory ow, which can
be challenging for small children, many elderly
individuals, or patients with strength disorders,
limiting their use in these groups45,46. However,
the issue present in pMDIs regarding the need
to coordinate inspiration with the manual acti-
vation of the device in a synchronized manner is
excluded since inhalation itself is the activation
mechanism47.
Considering the pillars of ESG (Environ-
mental, Social, and Governance), in relation to
the social aspect associated with nancial im-
plications, there is the “social cost of carbon”
(SCC), measured in dollars per ton of carbon,
which is an estimate of the monetary damag-
es associated with increased carbon emissions
in a year. An analysis by the American agency
responsible for this issue estimated an average
of approximately $25.80 per ton of carbon for
the year 201948. According to a UN report, every
10
Simões PF et al.
dollar invested in restoration creates up to $30
in economic benets49. us, it is likely that re-
ducing greenhouse gas emissions from inhaled
medications will result in signicant economic
benets, avoiding costs related to the preserva-
tion or recovery of the health of the planet and
people due to climate change.
For comparison purposes, the most recent
climate disaster in Brazil, the oods in Rio
Grande do Sul, cost the government R$ 12.8 bil-
lion, according to data from the National Con-
federation of Municipalities50. erefore, if we
consider the costs of the negative externalities of
pMDIs on the planet and, consequently, on peo-
ple’s health, the cost of pMDIs could exceed the
cost of DPIs. In other words, the social cost of
carbon (SCC) should also be taken into account
in the cost analysis when choosing medications
dispensed by the SUS.
In addition to cost, there is another pillar of
ESG: corporate governance, in which institu-
tions must adopt a sustainable approach in their
management, considering the environmental
and social impacts of their operations, as well
as ensuring transparency and accountability in
corporate management21.
Regarding asthma, the therapeutic option of
Salbutamol and/or Beclometasone (pMDI) has
not been the rst choice of treatment since 2020,
when GINA51,52 pointed out, based on scientif-
ic ndings with an adequate level of evidence,
an advancement in treatment toward better
outcomes in asthma health indicators. Among
the rst-step options for asthma, the use of For-
moterol + Budesonide (available in the form of
DPI) is the most recommended and preferred
option by the current guideline, instead of rely-
ing solely on medications in pMDI form. is
recommendation arose from the observed clin-
ical benet of its use: a 37% reduction in hos-
pitalizations and severe asthma exacerbations
requiring oral corticosteroid use52. Regarding
COPD, the treatment for both maintenance and
prevention as well as for quick relief is based on
long-acting beta-agonists and antimuscarinics
(LABAs and LAMAs, respectively), which are
widely available in DPI form and some in SMI19.
e DPI Formoterol + Budesonide and
Umeclidinium + Vilanterol, as well as the SMI
Olodaterol + Tiotropium, are available through
the SUS in Special Medication Pharmacies in
some states of Brazil, such as Rio Grande do
Sul, for the ICDs of asthma (only Formoterol +
Budesonide) and COPD (all the aforementioned
medications), upon presentation of reports and
tests. is process requires greater bureaucratic
work from the prescriber and delays the release
of medication for the patient. In a context like
that of Primary Health Care (APS) within the
SUS, where professionals need to manage con-
sultation times, this process may bias the pre-
scriber’s preferred choice, which is a practically
vital perspective.
is study has some limitations. Firstly, the
amount of HFA-134a present in the inhalers is
not publicly available in the drug package in-
serts, and there is a risk that it varies by man-
ufacturer. For its estimation, data from English
literature were used6,53-56. erefore, it is import-
ant to reiterate that the result will be an estimate,
as the SUS dispenses medications from dier-
ent laboratories and, consequently, there may
be slight dierences in their formulas and the
amount of gas in the nal product.
Additionally, the dispensing data obtained
for “the SUS as a whole” from BNAFAR, which
excludes dispensations from the Popular Phar-
macy, are primarily related to dispensations in
Primary Care. However, depending on local
organization and management, it cannot be ex-
cluded that some locations count the data dis-
pensed in Urgent Care Centers or Hospitals. It
is worth noting that during severe acute exac-
erbations of asthma and COPD in emergency
settings, the use of short-acting bronchodilators
as rescue (available as Salbutamol pMDI) is the
most studied and is appropriate. Furthermore,
not all municipalities transmit their data to
BNAFAR, leading to an underestimation of the
number of dispensations. It is known that dis-
pensations related to the Popular Pharmacy cor-
respond to prescriptions at the outpatient level.
Secondly, for the calculation of the carbon
footprint (CF), the amount of propellant gas
was multiplied by its Global Warming Potential
(GWP). e total CF of the medications, which
accounts for the energy consumed in their man-
ufacture and transportation, was not calculated.
us, the data presented here can be considered
signicantly underestimated, although if there
were a switch to DPI or SMI, the CF of their
manufacture and transportation would likely
be comparable. We hope that by identifying the
gap in the absence of these data in the Brazil-
ian context, this study will encourage further
research.
irdly, unfortunately, data on the dis-
pensing of all the dierent types of inhalers
dispensed through the SUS in Brazil, such as
those for Formoterol with Budesonide (DPI)
or Olodaterol with Tiotropium (SMI), were not
provided. erefore, it was not possible to cal-
11
Ciência & Saúde Coletiva, 30(9):1-14, 2025
culate the percentage of pMDI dispensations in
relation to the total and, additionally, estimate
the reduction that could occur if Brazil adopted
a standard similar to that of other countries. It
was also impossible to calculate the CO2 emis-
sions per patient and compare this data with that
of other countries, as the information provided
by the Brazilian government describes only the
number of devices dispensed without detailing
how many individuals received the medications.
Finally, the cost calculation for the substitu-
tion of pMDIs for DPIs is an estimate (which
could be over or underestimated), given that
information on how many individuals benet-
ed from the prescription of Salbutamol and/or
Beclometasone was not provided, nor is there
knowledge of the prescription pattern indicated
for each individual based on their asthma stag-
ing. Future projects are also suggested to con-
duct more detailed cost calculations consider-
ing the negative externalities of pMDIs.
e primary material and the methodologi-
cal details used to arrive at the results presented
in this article will be shared in a certied data
repository, as part of the process known as
Open Science.
is research had the innovative character of
seeking to unveil the signicant carbon footprint
associated with asthma treatment in the SUS due
to the preferential dispensing of pMDIs, in addi-
tion to making cost estimates. e substitution
of pMDIs for DPIs or SMIs brings clinical ben-
ets for asthma and COPD control and would
be an eective measure for healthcare services
in relation to climate change, promoting better
public and planetary health for all.
Collaborations
P Flamia and TPB Silva contributed to the
conception, project design, acquisition, anal-
ysis and interpretation of data, article writing,
and approved the nal version. EF Barros, KP
Patrício and RB Zandavalli contributed to the
conception, study design, analysis and interpre-
tation of data, relevant critical review of intel-
lectual content, and approved the nal version.
Data availability statement
e dataset for this article is available in the
SciELO Data repository in the Ciência & Saúde
Coletiva Dataverse, at the link: https://doi.
org/10.48331/SCIELODATA.OVAOFJ.
12
Simões PF et al.
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Article submitted 09/04/2024
Approved 13/09/2024
Final version submitted 15/09/2024
Chief editors: Maria Cecília de Souza Minayo, Romeu
Gomes, Antônio Augusto Moura da Silva, Vânia de Matos
Fonseca
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