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Reducing the carbon footprint of inhaler prescriptions at an Australian tertiary health service: a modelling exercise PDF Free Download

Reducing the carbon footprint of inhaler prescriptions at an Australian tertiary health service: a modelling exercise PDF free Download. Think more deeply and widely.

1
Title Page
Title:
Reducing the carbon footprint of inhaler prescriptions at an Australian tertiary health
service: a modelling exercise
Authors
Joshua VB Taverner1,2
Lata Jayaram1,3
Author A.iliations
1 Western Health, Melbourne, Victoria, Australia
2 Alfred Health, Melbourne, Victoria, Australia
3 The University of Melbourne, Melbourne, Victoria, Australia
Corresponding Author
Dr. Joshua Taverner
Western Health
176 Furlong Road, St Albans VIC 3021, Australia
Email: Joshua.taverner1@wh.org.au
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted July 14, 2025. ; https://doi.org/10.1101/2025.07.12.25331451doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
2
Abstract 1
Background: 2
!"#$%&'()*%+,'(-./'/(/#,+#0)%+&(*'%"&*(1#/2/3(-%1&#)4"%1"5(6.1(1'/-#1%&.15(-%&#'+&/7(8'%"&*)%1'(/5/&'$/(3
).+&1#94&'(/49/&%+&#%""5(&.(,1''+*.4/'(,%/('$#//#.+/3(:#&*(#+*%"'1/(1'-1'/'+&#+,(%(+.&%9"'(/.41)'7(4
;'&'1'<(<./'(#+*%"'1/().+&%#+(*5<1.=4.1.)%19.+/(:#&*(,".9%"(:%1$#+,(-.&'+&#%"/(>3?@@A?3?B@(&#$'/(&*%&(5
.6()%19.+(<#.C#<'3(:*#"'(<15(-.:<'1(#+*%"'1/(%+<(/.6&($#/&(#+*%"'1/(*%D'(+',"#,#9"'('$#//#.+/7(E'/-#&'(6
,4#<'"#+'/(1').$$'+<#+,('+D#1.+$'+&%""5(61#'+<"5(%"&'1+%&#D'/3("#$#&'<(<%&%('C#/&/(.+(F4/&1%"#%+(*./-#&%"(7
<#/)*%1,'(-1'/)1#9#+,(-%&&'1+/(%+<(&*'#1('+D#1.+$'+&%"(#$-%)&7(8
9
Methods: 10
G'().+<4)&'<(%(1'&1./-')&#D'(<'/)1#-&#D'(/&4<5(.6(%""(#+*%"'1(-1'/)1#-&#.+/(%&(<#/)*%1,'(61.$(G'/&'1+(11
8'%"&*3(H#)&.1#%3(61.$(I%+4%15(>(&.(E')'$9'1(?>3(J@J?7(E'A#<'+&#0'<(-1'/)1#-&#.+(<%&%(:'1'('C&1%)&'<(12
61.$('"')&1.+#)($'<#)%"(1').1</(:#&*.4&('C)"4/#.+/7(G'()%")4"%&'<(&.&%"(-1'/)1#-&#.+/(95(<'D#)'(&5-'(%+<(13
$'<#)%&#.+()"%//3('/&#$%&'<()%19.+('$#//#.+/(4/#+,(-49"#/*'<(-1.-'""%+&(<%&%3(%+<($.<'""'<(-.&'+&#%"(14
'$#//#.+(1'<4)&#.+/(61.$(/:#&)*#+,($'&'1'<(<./'(#+*%"'1/(&.(<15(-.:<'1(#+*%"'1/(:*'1'()"#+#)%""5(15
%--1.-1#%&'7(K)'+%1#./(#+)"4<'<(>@L3(B@L3(MBL3(%+<(>@@L().+D'1/#.+(1%&'/7(16
(17
Results: 18
N6(>O3POQ(#+*%"'1(-1'/)1#-&#.+/3(P>7MPL(:'1'($'&'1'<(<./'(#+*%"'1/3(JJ7>>L(<15(-.:<'1(#+*%"'1/3(%+<(19
O7@JL(/.6&($#/&(#+*%"'1/7(K*.1&A%)&#+,($'<#)%&#.+/().$-1#/'<(BJ7PL(.6(-1'/)1#-&#.+/3(:#&*(QQ7@L(.6(20
/*.1&A%)&#+,(9'&%A%,.+#/&/(-1'/)1#9'<(%/($'&'1'<A<./'(#+*%"'1/7(R.&%"('/&#$%&'<()%19.+('$#//#.+/(:'1'(21
JQO7?B(&.++'/()%19.+(<#.C#<'('S4#D%"'+&3(:#&*($'&'1'<A<./'(#+*%"'1/().+&1#94&#+,(QM7PQL(TJQJ7M(22
&.++'/U7(K*.1&A%)&#+,(9'&%A%,.+#/&/(%".+'(%)).4+&'<(6.1(OV7JJL(.6(&.&%"('$#//#.+/7(W6(%""()"#+#)%""5(23
%--1.-1#%&'($'&'1'<A<./'(#+*%"'1/(:'1'(/:#&)*'<(&.(<15(-.:<'1(#+*%"'1/3('$#//#.+/(:.4"<(<')1'%/'(95(24
JOP7PQ(&.++'/(TQ@7?OL(1'<4)&#.+U7(;.1'($.<'/&()*%+,'/(:.4"<(5#'"<(/49/&%+&#%"(9'+'0&/X(MBL(25
).+D'1/#.+(TJJP7OJ(&.++'/(1'<4)&#.+U3(B@L().+D'1/#.+(T>??7MQ(&.++'/U3(%+<(>@L().+D'1/#.+(TJO7PM(26
&.++'/U7(27
(28
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted July 14, 2025. ; https://doi.org/10.1101/2025.07.12.25331451doi: medRxiv preprint
3
Conclusions 29
R*#/(/&4<5(%<<1'//'/(%()1#&#)%"(2+.:"'<,'(,%-(95(-1.D#<#+,(&*'(01/&().$-1'*'+/#D'(%+%"5/#/(.6(*./-#&%"(30
<#/)*%1,'(#+*%"'1(-1'/)1#-&#.+/(%+<(&*'#1('+D#1.+$'+&%"(#$-%)&(#+(F4/&1%"#%7(;'&'1'<A<./'(#+*%"'1(31
-1'/)1#-&#.+/(%&(*./-#&%"(<#/)*%1,'().+&1#94&'(<#/-1.-.1&#.+%&'"5(&.(*'%"&*)%1'()%19.+('$#//#.+/3(:#&*(32
&*'($%Y.1#&5().$#+,(61.$(/*.1&A%)&#+,($'<#)%&#.+/7(K49/&%+&#%"('$#//#.+(1'<4)&#.+/(%1'(%)*#'D%9"'(33
&*1.4,*(&*'(-1'6'1'+&#%"(-1'/)1#9#+,(.6(<15(-.:<'1(#+*%"'1/(:*'1'()"#+#)%""5(%--1.-1#%&'7(8./-#&%"(34
<#/)*%1,'(1'-1'/'+&/(%()1#&#)%"(#+&'1D'+&#.+(-.#+&3(%/(&*'/'(-1'/)1#-&#.+/(.6&'+(&'$-"%&'(.+,.#+,(35
).$$4+#&5(-1'/)1#9#+,7(R*'/'(0+<#+,/(-1.D#<'('//'+&#%"(9%/'"#+'(<%&%(6.1(#$-"'$'+&#+,(F4/&1%"#%Z/(36
[%&#.+%"(8'%"&*(%+<(!"#$%&'(K&1%&',5(%+<(%)*#'D#+,(/#,+#0)%+&(*'%"&*)%1'('$#//#.+(1'<4)&#.+/(:*#"'(37
$%#+&%#+#+,(S4%"#&5()%1'7(38
(39
G.1<().4+&X(?VQ 40
Keywords 41
;'K8(&'1$/(42
>7 !"#$%&'()*%+,'((43
J7 ;'&'1'<(<./'(#+*%"'1((44
?7 E15(\.:<'1(W+*%"'1/(45
V7 ]4+,(E#/'%/'/3(N9/&14)&#D'(46
B7 F4/&1%"#%((47
O7 ^1''+*.4/'(^%/'/(48
P7 \%&#'+&(E#/)*%1,'(49
M7 E14,(\1'/)1#-&#.+/(50
Q7 !%19.+(E#.C#<'_%+%"5/#/(51
>@7 \1%)&#)'(\%&&'1+/3(\*5/#)#%+/(52
53
54
55
56
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted July 14, 2025. ; https://doi.org/10.1101/2025.07.12.25331451doi: medRxiv preprint
4
Article 57
Background 58
!"#$%&'()*%+,'(-./'/(4+-1')'<'+&'<(&*1'%&/(&.(,".9%"(*'%"&*3(:#&*(1'/-#1%&.15(-%&#'+&/(-%1&#)4"%1"5(59
D4"+'1%9"'(&.(#+)1'%/'<(-.""'+(".%</3(&*4+<'1/&.1$(%/&*$%('D'+&/3(%+<(:.1/'+#+,(%#1(S4%"#&5(T>UTJU7(60
^1''+*.4/'(,%/('$#//#.+/(&1%-(*'%&(#+(&*'(`%1&*Z/(%&$./-*'1'3("'%<#+,(&.(,".9%"(:%1$#+,(%+<()"#$%&'(61
)*%+,'3(:*#)*(#+(&41+()1'%&'/(&*'/'(*'%"&*(1#/2/7(8'%"&*)%1'(/5/&'$/(&*'$/'"D'/().+&1#94&'().+/#<'1%9"5(62
&.(&*#/(-1.9"'$(&*1.4,*(&*'#1(,1''+*.4/'(,%/('$#//#.+/7(R*'(F4/&1%"#%+(*'%"&*)%1'(/5/&'$().+&1#94&'/(%/(63
$4)*(%/(PL(.6(F4/&1%"#%Z/(,1''+*.4/'(,%/('$#//#.+/(TJU3(/#,+#0)%+&"5(*#,*'1(&*%+(&*'(V7VL(,".9%"(%D'1%,'(64
T?U7(W+*%"'1/(4/'<(&.(&1'%&(1'/-#1%&.15(<#/'%/'/(/4)*(%/(%/&*$%(.1()*1.+#)(.9/&14)&#D'(-4"$.+%15(<#/'%/'(65
T!N\EU(*%D'(9''+(/*.:+(&.(9'(1'/-.+/#9"'(6.1(?L(.6(*'%"&*)%1'(/')&.1('$#//#.+/(#+(&*'().$-%1%9"'(66
a+#&'<(b#+,<.$(TabU([%&#.+%"(8'%"&*(K'1D#)'(T[8KUTVU7((67
(68
;'&'1'<(<./'(#+*%"'1/(T;EW/U(%1'(&*'($./&(-1'/)1#9'<(<'D#)'(&5-'(%+<().+&%#+(*5<1.=4.1.)%19.+/(69
T8c!/U7(85<1.=4.1.)%19.+/(*%D'(%().+/#<'1%9"'(,".9%"(:%1$#+,(-.&'+&#%"(T^G\U3(:*#)*($'%/41'/(*.:(70
$4)*(*'%&(%(,%/(&1%-/().$-%1'<(&.()%19.+(<#.C#<'(T!N2U(.D'1(%(>@@A5'%1(-'1#.<3(&*'1'95().+&1#94&#+,(&.(71
)"#$%&'()*%+,'7(R*'(8c!/().$$.+"5(4/'<(#+(;EW/(#+)"4<'(8c!A>?V%(%+<(8c!AJJP'%3(:*#)*(*%D'(^G\(72
D%"4'/(.6(>3?@@(%+<(?3?B@(&#$'/(&*%&(.6()%19.+(<#.C#<'3(1'/-')&#D'"57(d5().+&1%/&3(E15(\.:<'1(W+*%"'1/(73
TE\W/U(%+<(K.6&(;#/&(W+*%"'1/(TK;W/U(<.(+.&().+&%#+(*5<1.=4.1.)%19.+(-1.-'""%+&/(%+<().+&1#94&'(74
+',"#,#9"'(,1''+*.4/'(,%/('$#//#.+/(TVU3(*'1'%6&'1(1'6'11'<(&.(%/(e)%19.+('$#//#.+/f7(;./&($'<#)%&#.+/(75
%<$#+#/&'1'<(D#%(;EW(%1'(%"/.(%D%#"%9"'(D#%(E\W(#+(F4/&1%"#%3(.1(&*'1'(%1'($'<#)#+'/(.6(&*'(/%$'()"%//(%+<(76
'g#)%)5(%D%#"%9"'(D#%(E\W7(G#&*(/.$'('C)'-&#.+/3(%"$./&(%""(-%&#'+&/()%+(9'(/%6'"5(-1'/)1#9'<(%+(77
'+D#1.+$'+&%""5(61#'+<"5(#+*%"'1(:#&*('S4%"(.1(/4-'1#.1(.4&).$'/(&*%+(:.4"<(9'(%)*#'D'<(D#%(;EW(TBU7(78
(79
!*%+,#+,(#+*%"'1(-1'/)1#-&#.+/(&.(".:A)%19.+(%"&'1+%&#D'/(%"#,+/(:#&*(".)%"(,4#<'"#+'/(61.$(&*'(R*.1%)#)(80
K.)#'&5(.6(F4/&1%"#%(%+<([':(h'%"%+<(TRKF[hU(TOU(%+<(#+&'1+%&#.+%"(,4#<'"#+'/(/4)*(%/(&*./'(95(&*'(d1#&#/*(81
R*.1%)#)(K.)#'&5(T>3JU7((W+(F4/&1%"#%3(&*'([%&#.+%"(8'%"&*(%+<(!"#$%&'(K&1%&',53(1'"'%/'<(#+(E')'$9'1(82
J@J?3(%#$/(&.(1'<4)'(&*'('+D#1.+$'+&%"(#$-%)&(.6(*'%"&*)%1'7(R*'(1'<4)&#.+(#+()%19.+('$#//#.+/(61.$(83
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted July 14, 2025. ; https://doi.org/10.1101/2025.07.12.25331451doi: medRxiv preprint
5
#+*%"'1(4/'(*%/(9''+(#<'+&#0'<(%/(%+(%1'%(6.1(#$-1.D'$'+&(TPU7(;%+5(-%&#'+&/(%1'($.&#D%&'<(&.().+/#<'1(84
'+D#1.+$'+&%"(#$-%)&(:*'+()*../#+,(&*'#1(#+*%"'13(%+<(%()*%+,'(#+(#+*%"'1/()%+(1'<4)'()%19.+(85
'$#//#.+/().$-%1%9"'(&.(/:#&)*#+,(61.$(%(,%/."#+'(&.(%(*591#<()%1(.1(%<.-&#+,(%(-"%+&A9%/'<(<#'&TOUTMU7(86
(87
E'/-#&'(&*#/3(&*'1'(#/("#$#&'<(-49"#/*'<(<%&%(.+(#+*%"'1(<'D#)'(-1'/)1#-&#.+/(#+(F4/&1%"#%3('/-')#%""5(4-.+(88
*./-#&%"(<#/)*%1,'7(R.(%<<1'//(&*#/(2+.:"'<,'(,%-3(&*#/(/&4<5(%#$/(&.(S4%+&#65(&*'(-1.-.1&#.+(.6('%)*(89
#+*%"'1(<'D#)'(-1'/)1#9'<(.+(<#/)*%1,'(61.$(%("%1,'($'&1.-."#&%+(*./-#&%"(#+(;'"9.41+'(%+<(&.('/&#$%&'(90
&*'()%19.+(#$-%)&(61.$(&*'(-1'/)1#9'<(#+*%"'1/(4/#+,(-1'D#.4/"5(-49"#/*'<(<%&%7(d5()%")4"%&#+,(-.&'+&#%"(91
)%19.+(/%D#+,/(61.$(1'<4)#+,(;EW(-1'/)1#-&#.+/3(&*#/(/&4<5(:#""('/&#$%&'(&*'('+D#1.+$'+&%"(9'+'0&/(.6(92
%<.-&#+,($.1'(".:A)%19.+(#+*%"'1(-1'/)1#9#+,(-1%)&#)'/(%&(<#/)*%1,'7(93
(94
Methods 95
G'(-'16.1$'<(%(1'&1./-')&#D'(<'/)1#-&#D'(/&4<5(.6(#+*%"'1(-1'/)1#-&#.+/(.+(<#/)*%1,'(61.$(G'/&'1+(96
8'%"&*3(H#)&.1#%3(61.$(I%+4%15(>(&.(E')'$9'1(?>3(J@J?7(G'/&'1+(8'%"&*(#/(%("%1,'($'&1.-."#&%+(*'%"&*(97
/'1D#)'().$-1#/#+,(&:.($%Y.1(*./-#&%"/(%+<(/'D'1%"(/$%""'1(6%)#"#&#'/(#+(:'/&'1+(;'"9.41+'3(/'1D#+,(%(98
<#D'1/'(-.-4"%&#.+(:#&*(&*1''('$'1,'+)5(<'-%1&$'+&/(%+<(/-')#%"#/'<(4+#&/3(#+)"4<#+,(1'/-#1%&.153(99
,'+'1%"($'<#)#+'3(%+<(,'1#%&1#)/7(F6&'1(.9&%#+#+,('&*#)/(%--1.D%"(61.$(&*'(G'/&'1+(8'%"&*('&*#)/(100
).$$#&&''(T`&*#)/(+4$9'1(P?JOV@QU3(:'(.9&%#+'<(<'A#<'+&#0'<(#+*%"'1(-1'/)1#-&#.+/(.+(<#/)*%1,'(6.1(101
'D'15(-%&#'+&(:#&*(%+(#+-%&#'+&(/&%5(%&(G'/&'1+(8'%"&*(#+(&*'(5'%1(J@J?(D#%(<%&%().""')&#.+(61.$(&*'(102
'"')&1.+#)($'<#)%"(1').1<7(G'(<#<(+.&('C)"4<'(%+5(-%&#'+&/(.1(-1'/)1#-&#.+/(61.$(&*#/(/&4<57(!"#+#)%"(103
<'&%#"/(:'1'(4+%D%#"%9"'(%/(-%&#'+&(1').1</(:'1'(+.&(%))'//'<7(R*'(<%&%(:%/(/&.1'<(#+(%(-%//:.1<A104
-1.&')&'<(`C)'"(0"'(.+(&*'(*./-#&%"(/'1D'13(%+<()%")4"%&#.+/(%+<(%+%"5/#/(:'1'(-'16.1$'<(4/#+,(;#)1./.6&(105
`C)'"(%+<(0,41'/()1'%&'<(:#&*(8R;]7((106
(107
G'()%")4"%&'<(&*'(&.&%"(-1'/)1#-&#.+(.6('%)*(#+*%"'<($'<#)%&#.+(95(<'D#)'(&5-'3(%//4$#+,('%)*(108
-1'/)1#-&#.+(:%/(0""'<(.+)'(6."".:#+,(*./-#&%"(<#/)*%1,'3(:#&*.4&(%//4$#+,(1'-'%&(-1'/)1#-&#.+/(.1(109
).+&#+4'<(-1'/)1#-&#.+/(:#&*#+(&*'().$$4+#&53(%/(:'().4"<(+.&(4&#"#/'().$$4+#&5(-*%1$%)5(<#/-'+/#+,(110
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted July 14, 2025. ; https://doi.org/10.1101/2025.07.12.25331451doi: medRxiv preprint
6
<%&%7(G'()%")4"%&'<(&*'(&.&%"()%19.+('$#//#.+/(6.1('%)*(#+*%"'1(4/#+,()%19.+(6..&-1#+&('/&#$%&'/(95(111
R#14$%"%/'&&5('&(%"73(:*#)*(:'1'(<'1#D'<(61.$(-1.-'""%+&(:'#,*&3(,".9%"(:%1$#+,(-.&'+&#%"(D%"4'/3(%+<(112
"#6')5)"'(%+%"5/#/(<%&%7(8.:'D'13(&*'/'('/&#$%&'/()%115(4+)'1&%#+&5(<4'(&.(1'"#%+)'(.+($%&'1#%"(/%6'&5(113
<%&%(/*''&/(1%&*'1(&*%+(<#1')&($'%/41'$'+&(%+<('C&1%-."%&#.+(.6($%+46%)&41#+,('$#//#.+/(TQU7(G'(&*'+(114
)%")4"%&'<(&*'(&.&%"()%19.+('$#//#.+(6.1('%)*()"%//(.6($'<#)%&#.+(%+<('%)*().$9#+%&#.+(.6()"%//'/7(115
\1'D'+&'1(#+*%"'1/(&5-#)%""5().+&%#+(%(.+'A$.+&*(/4--"5(.6($'<#)%&#.+3(%+<(F4/&1%"#%+(*./-#&%"/(%1'(116
1'/-.+/#9"'(6.1(-1'/)1#9#+,($'<#)%&#.+/(&.().D'1(&*'($.+&*(6."".:#+,(<#/)*%1,'7(R*'1'6.1'3(.41(%+%"5/#/(117
1'-1'/'+&/()%19.+('$#//#.+/(61.$(#+*%"'1/(6.1(&*'(01/&($.+&*(-./&A<#/)*%1,'7(R*#/(<'/)1#-&#D'(/&4<5(<#<(118
+.&(1'S4#1'(/&%&#/&#)%"(&'/&#+,(%/(:'(%+%"5/'<(%""(<#/)*%1,'(-1'/)1#-&#.+/(1%&*'1(&*%+(%(/%$-"'7(119
(120
c.1('%)*(;EW(-1'/)1#9'<3(:'(#<'+&#0'<('+D#1.+$'+&%""5(61#'+<"5(E\W(%"&'1+%&#D'/(:#&*(/49/&%+&#%""5(".:'1(121
)%19.+('$#//#.+/3(#6(-.//#9"'7(G*'1'(%D%#"%9"'3(:'(#<'+&#0'<(%(E\W(:#&*(&*'(/%$'($'<#)%&#.+T/U(.13(#6(+.&(122
-.//#9"'3(%(E\W(:#&*($'<#)%&#.+T/U(61.$(&*'(/%$'()"%//(%+<(.6('S4#D%"'+&('g#)%)57(G'(&*'+()%")4"%&'<(&*'(123
'/&#$%&'<()%19.+('$#//#.+/(#6(>@L3(B@L3(.1(MBL(.1(%""(;EW/(:'1'()*%+,'<(&.(E\W/7(G'(/'"')&'<(&*'/'(124
'/&#$%&'/(&.(1'-1'/'+&(%($.<'/&(-'1)'+&%,'()*%+,'(T>@LU3(%(/49/&%+&#%"()*%+,'(TB@LU3(.1(%()*%+,'(&*%&(125
:.4"<(%"#,+(F4/&1%"#%+(-1'/)1#-&#.+/(:#&*(&*./'(#+(K:'<'+(TMBLU7(R*'(-.&'+&#%"()%19.+(/%D#+,/(:'1'(&*'+(126
)%")4"%&'<(&.(-1.D#<'(%+('/&#$%&'(6.1(*.:()*%+,#+,(*./-#&%"(-1'/)1#-&#.+/(:.4"<(<#1')&"5(1'<4)'(&*'(127
'+D#1.+$'+&%"(#$-%)&(.6(#+*%"'1/7(((128
(129
Results(130
F(&.&%"(.6(>O3POQ(#+*%"'1/(:'1'(-1'/)1#9'<(%&(G'/&'1+(8'%"&*(#+(J@J?(TR%9"'(>U3(:#&*(/*.1&A%)&#+,(%,'+&/(131
).$-1#/#+,(.D'1(*%"6(TBJ7PLU(.6(%""(-1'/)1#-&#.+/7(R%9"'(>(-1.D#<'/(%(<'&%#"'<(91'%2<.:+(.6(-1'/)1#-&#.+/(132
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(251
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%<*'1'+)'( -%&&'1+/( 6."".:#+,( <'D#)'( /:#&)*'/7( F/( F4/&1%"#%( <'D'".-/( #&/( [%&#.+%"( 8'%"&*( %+<( !"#$%&'(281
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List of abbreviations
CO₂ - Carbon dioxide
CO₂e - Carbon dioxide equivalent
COPD - Chronic obstructive pulmonary disease
DPI - Dry powder inhaler
GWP - Global warming potential
HFC - Hydrofluorocarbon
ICS - Inhaled corticosteroid
ICS/LABA - Inhaled corticosteroid/Long-acting beta-agonist combination
ICS/LABA/LAMA - Inhaled corticosteroid/Long-acting beta-agonist/Long-acting muscarinic
antagonist triple therapy
LABA - Long-acting beta-agonist
LAMA - Long-acting muscarinic antagonist
LABA/LAMA - Long-acting beta-agonist/Long-acting muscarinic antagonist combination
MDI - Metered dose inhaler
NHS - National Health Service
SABA - Short-acting beta-agonist
SAMA - Short-acting muscarinic antagonist
SMI - Soft mist inhaler
TSANZ - Thoracic Society of Australia and New Zealand
UK - United Kingdom
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Declarations
Ethics approval
R*#/(/&4<5(:%/(%--1.D'<(95(&*'(G'/&'1+(8'%"&*(i'/'%1)*(Ng#)'(%/(%(;#+#$%"(i#/2(i'/'%1)*(-1.Y')&(
TnF_>>VOJQ_G8AJ@JBAVMBO?VTD?Uo(].)%"(i'6'1'+)'([4$9'1X(nFJ@JV7>@BU(.+(?(I4+'(J@JB7(R*'(-1.Y')&(
$'&(&*'(1'S4#1'$'+&/(.6(&*'([%&#.+%"(K&%&'$'+&(.+(`&*#)%"(!.+<4)&(#+(84$%+(i'/'%1)*(T[8;i!3(J@J?U3(
&*'(F4/&1%"#%+(!.<'(6.1(&*'(i'/-.+/#9"'(!.+<4)&(.6(i'/'%1)*(T[8;i!3(J@>MU3(%+<(:%/().+/#/&'+&(:#&*(
`&*#)%"(!.+/#<'1%&#.+/(#+(n4%"#&5(F//41%+)'(%+<(`D%"4%&#.+(F)&#D#&#'/(T[8;i!3(J@>VU7(F/(&*#/(:%/(%(
1'&1./-')&#D'(/&4<5(4/#+,(<'A#<'+&#0'<(-1'/)1#-&#.+(<%&%('C&1%)&'<(61.$('"')&1.+#)($'<#)%"(1').1</3(
#+<#D#<4%"(-%&#'+&().+/'+&(:%/(+.&(1'S4#1'<7(
(
Consent for publication
[.&(%--"#)%9"'(
(
Availability of data and materials
R*'(<%&%/'&/(,'+'1%&'<(%+<(%+%"5/'<(<41#+,(&*#/(/&4<5(%1'(+.&(-49"#)"5(%D%#"%9"'(<4'(&.(-%&#'+&(
).+0<'+&#%"#&5(1'/&1#)&#.+/(%+<(&*'(&'1$/(.6('&*#)/(%--1.D%"(94&(%,,1',%&'(1'/4"&/(%1'(-1'/'+&'<(#+(64""(
:#&*#+(&*#/(%1&#)"'7(
(
Competing interests
I7R(7(*%/(+.().$-'&#+,(#+&'1'/&/(&.(<')"%1'(
]7I7(*%/(+.().$-'&#+,(#+&'1'/&/(&.(<')"%1'(
Funding
None received
Authors' contributions
I7R7().+)'#D'<(%+<(<'/#,+'<(&*'(/&4<53(.9&%#+'<('&*#)/(%--1.D%"3(-'16.1$'<(<%&%('C&1%)&#.+(%+<(%+%"5/#/3(
).+<4)&'<(%""()%19.+('$#//#.+()%")4"%&#.+/3(%+<(<1%6&'<(&*'($%+4/)1#-&7((
]7I7().+&1#94&'<(&.(/&4<5(<'/#,+3(%//#/&'<(:#&*($%+4/)1#-&(:1#&#+,3(%+<(-1.D#<'<()1#&#)%"(1'D#/#.+(.6(&*'(
$%+4/)1#-&(6.1(#$-.1&%+&(#+&'""')&4%"().+&'+&7(d.&*(%4&*.1/(1'%<(%+<(%--1.D'<(&*'(0+%"($%+4/)1#-&7(
(
Acknowledgements
[.&(%--"#)%9"'(
(
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15
Tables/ Figures
Table 1: Distribution of Inhaler Prescriptions by Medication Class and
Device Type
Medication Class
MDI
DPI
SMI
Total
K*.1&AF)&#+,(d'&%AF,.+#/&(TKFdFU
(
P3B?V
(
PO
(
@
(
P3O>@
(
K*.1&AF)&#+,(;4/)%1#+#)(F+&%,.+#/&(TKF;FU(
>3J?B(
@
(
@
(
>3J?B(
].+,AF)&#+,(d'&%AF,.+#/&(T]FdFU(
@(
JO
(
@
(
JO(
].+,AF)&#+,(;4/)%1#+#)(F+&%,.+#/&(T]F;FU(
@(
P>P
(
PPV
(
>3VQ>(
]FdF_]F;F(!.$9#+%&#.+(
@(
>PQ
(
J?B
(
V>V(
W+*%"'<(!.1&#)./&'1.#<(TW!KU(
VMV(
JPJ
(
@
(
PBO(
W!K_]FdF(!.$9#+%&#.+(
J3?>Q(
>3VOV
(
@
(
?3PM?(
W!K_]FdF_]F;F(R1#-"'(R*'1%-5(
VM@(
QPV
(
@
(
>3VBV(
TOTAL(
12,052(
3,708
(
1,009
(
16,769(
Percentage by Device(
71.87%(
22.11%
(
6.02%
(
100.00%(
Legend:(KFdF(p(K*.1&AF)&#+,(d'&%AF,.+#/&o(KF;F(p(K*.1&AF)&#+,(;4/)%1#+#)(F+&%,.+#/&o(]FdF(p(].+,A
F)&#+,(d'&%AF,.+#/&o(]F;F(p(].+,AF)&#+,(;4/)%1#+#)(F+&%,.+#/&o(W!K(p(W+*%"'<(!.1&#)./&'1.#<o(;EW(p(
;'&'1'<(E./'(W+*%"'1o(E\W(p(E15(\.:<'1(W+*%"'1o(K;W(p(K.6&(;#/&(W+*%"'17(E%&%(1'-1'/'+&/(#+*%"'1(
-1'/)1#-&#.+/(<#/-'+/'<(%&(%(&'1&#%15(*./-#&%"(.D'1(>JA$.+&*(/&4<5(-'1#.<7(
Table 2: Device-Specific Carbon Emissions Profile
Medication
Class
Device
Type
Device
Examples
Carbon
Emissions per
Device (grams
CO₂e)
Tota l
Prescriptions
% of Total
Prescriptions
Tota l
Emissions
(tonnes)
% of Total
Emissions
SABA
MDI
Ventolin, Airomir,
28,700
7,534
44.91%
190.3
64.22%
SABA
DPI
Terb ut aline
Turbuhaler
790
76
0.45%
0.06
0.02%
SAMA
MDI
Atrovent
14,590
1,235
7.36%
18.0
6.08%
LABA
DPI
Serevent Diskus
790
26
0.16%
0.02
0.01%
LAMA
DPI
Spiriva
HandiHaler
790
717
4.28%
0.57
0.19%
LAMA
SMI
Spiriva Respimat
775
774
4.62%
0.60
0.20%
ICS
MDI
Flixotide,
Alvesco
20,000
484
2.89%
9.7
3.27%
ICS
DPI
Pulmicort
Turbuhaler
790
272
1.62%
0.21
0.07%
LABA/LAMA
DPI
Anoro Ellipta
790
179
1.07%
0.14
0.05%
LABA/LAMA
SMI
Stiolto Respimat
775
235
1.40%
0.18
0.06%
ICS/LABA
MDI
Symbicort
Rapihaler,
Flutiform
36,500
2,319
13.83%
67.2
22.67%
ICS/LABA
DPI
Symbicort
Turbuhaler,
Seretide
Accuhaler
790
1,464
8.73%
1.16
0.39%
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16
Medication
Class
Device
Type
Device
Examples
Carbon
Emissions per
Device (grams
CO₂e)
Tota l
Prescriptions
% of Total
Prescriptions
Tota l
Emissions
(tonnes)
% of Total
Emissions
ICS/LABA/LAMA
MDI
Trimbow
15,000
480
2.86%
7.6
2.56%
ICS/LABA/LAMA
DPI
Trelegy Ellipta
790
974
5.81%
0.77
0.26%
TOTAL
All
Devices
—
—
16,769
100.00%
296.35
100.00%
Legend:(KFdF(p(K*.1&AF)&#+,(d'&%AF,.+#/&o(KF;F(p(K*.1&AF)&#+,(;4/)%1#+#)(F+&%,.+#/&o(]FdF(p(].+,A
F)&#+,(d'&%AF,.+#/&o(]F;F(p(].+,AF)&#+,(;4/)%1#+#)(F+&%,.+#/&o(W!K(p(W+*%"'<(!.1&#)./&'1.#<o(;EW(p(
;'&'1'<(E./'(W+*%"'1o(E\W(p(E15(\.:<'1(W+*%"'1o(K;W(p(K.6&(;#/&(W+*%"'1o(!Nq'(p(!%19.+(E#.C#<'(
`S4#D%"'+&7(!%19.+('$#//#.+/(<%&%(9%/'<(.+("#6')5)"'(%//'//$'+&(#+)"4<#+,($%+46%)&41#+,3(4/'3(%+<(
<#/-./%"(-*%/'/7(E'D#)'('C%$-"'/(1'-1'/'+&().$$.+"5(-1'/)1#9'<(91%+</(%D%#"%9"'(.+(&*'(F4/&1%"#%+(
\*%1$%)'4&#)%"(d'+'0&/(K)*'$'7(
(
Table 3: Current Carbon Emissions by Device Type
Device Type
Current Emissions (tonnes)
Percentage of Total
;'&'1'<(E./'(W+*%"'1/(T;EWU
(
JQJ7PP(
QM7PQL(
E15(\.:<'1(W+*%"'1/(TE\WU
(
J7PQ(
@7QVL(
K.6&(;#/&(W+*%"'1/(TK;WU
(
@7PM(
@7JOL(
TOTAL
(
296.35
(
100.00%
(
Legend:(;EW(p(;'&'1'<(E./'(W+*%"'1o(E\W(p(E15(\.:<'1(W+*%"'1o(K;W(p(K.6&(;#/&(W+*%"'17(
(
(
Table 4: Carbon Reduction Potential by Switching MDIs to DPIs
Scenario
MDIs Switched to
DPIs
Total Emiss ions
(tonnes)
Emissions Reduction
(tonnes)
Percentage
Reduction
!411'+&(K&%&'(
@L(
JQO7?B(
@7@@(
@7@@L(
;.<'/&(!*%+,'(
>@L(
JOQ7BP(
JO7PM(
Q7@VL(
K49/&%+&#%"(
!*%+,'(
B@L(
>OJ7VB(
>??7Q@(
VB7>ML(
K:'<'+(
F"#,+$'+&(
MBL(
OM7P?(
JJP7OJ(
PO7M>L(
;%C#$4$(
\.//#9"'r(
>@@L(
JM7BO(
JOP7PQ(
Q@7?OL(
Legend: MDI = Metered Dose Inhaler; DPI = Dry Powder Inhaler; SMI = Soft Mist Inhaler.
*Maximum conversion scenario excludes SAMA medications which are only available as
MDIs. Carbon emissions calculated using lifecycle assessment methodology including
manufacturing, propellant release, and disposal phases.
(
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Figure 1: Medication class prescriptions by device type
Figure 1.(\1.-.1&#.+(.6(<'D#)'(&5-'/(-1'/)1#9'<(:#&*#+('%)*($'<#)%&#.+()"%//(%&(G'/&'1+(8'%"&*(#+(J@J?7(
K*.1&A%)&#+,($'<#)%&#.+/(:'1'(%"$./&('C)"4/#D'"5(-1'/)1#9'<(%/(;EW/(TQQ7@L(.6(KFdF/3(>@@L(.6(KF;F/U7(
\1'D'+&#D'($'<#)%&#.+/(/*.:'<(,1'%&'1(D%1#%&#.+3(:#&*(W!K_]FdF().$9#+%&#.+/(-1'<.$#+%+&"5(-1'/)1#9'<(
%/(;EW/(TO>7?L(D/(?M7PL(E\W/U3(:*#"'(&1#-"'(&*'1%-5(#+*%"'1/(:'1'($.1'().$$.+"5(-1'/)1#9'<(%/(E\W/(
TOP7@L(D/(??7@L(;EW/U7(K#+,"'A%,'+&(]FdF/(%+<(]F;F/(%1'(.+"5(%D%#"%9"'(%/(E\W/_K;W/7(;EW(p($'&'1'<A
<./'(#+*%"'1o(E\W(p(<15(-.:<'1(#+*%"'1o(K;W(p(/.6&($#/&(#+*%"'17(
(
Figure 2: Carbon Emissions by inhaler (Tonnes)
Figure 2.(R.&%"()%19.+(<#.C#<'('S4#D%"'+&('$#//#.+/(TJQO7V(&.++'/U(95(<'D#)'(&5-'(%+<($'<#)%&#.+()"%//7(
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