Download PDFPDF

Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England
Compose Response

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g.
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests


  • A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
  • We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
  • Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
  • By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

  • Published on:
    Response to Levy et al.
    • Alexander K Wilkinson, Consultant Chest Physician East and North Herts NHS Trust
    • Other Contributors:
      • James N Smith, Assistant Director of Public Health Studies, University of Cambridge

    We are grateful to Levy et al for their comments on our paper.

    Much of the response to the paper has been to the media coverage and potential consequences of this. That MDIs have a large carbon footprint is hardly news within technical and academic literature. (1) It’s fair to say we were taken aback by the media response. Any guilt induced by headlines which focussed on individual change is deeply regrettable. Our paper was focussed on modelling at the NHS level. In-line with other previous reports we included an individual level comparison to provide context to our findings. (1-3) The “180-mile car journey” ascribed to us by Levy et al. originates from a story about NICE asthma inhalers decision aid.(4) Clearly we can’t control the media and have tried to correct errors in media reporting where possible. It is our opinion that it would be unethical and paternalistic to withhold significant information about treatment options from patients. As academic authors we are reflecting on how best to communicate information of the environmental impact of healthcare to the public and media, and considering how we might improve this in the future.

    Levy et al. highlight concerns “that all patients can be summarily switched from pMDIs to DPIs” or that patients are “deprived of access to pMDI therapy”. We do not propose this in the paper. In fact we make suggestions on how to reduce the greenhouse gas emissions from MDIs where their continuing use is necessary by prio...

    Show More
    Conflict of Interest:
    Dr. Smith reports personal fees from Trumpington Street Medical Practice, grants and personal fees from NHS England , personal fees from World Health Organisation Europe, personal fees from Better Value Healthcare Ltd, personal fees from Cambridgeshire County Council , personal fees from University of Cambridge, outside the submitted work; and he is married to a practicing GP in Cambridgeshire.
  • Published on:
    Key Reference unavailable

    Many thanks for bringing this to our attention. Unfortunately that report has been removed from their website and we are unable to add it now as a supplementary file. Here is an alternative reference published more recently which contains the same information:

    Janson C, Henderson R, Löfdahl M, et al. Carbon footprint impact of the choice of inhalers for asthma and COPD Thorax doi: 10.1136/thoraxjnl-2019-213744

    The findings presented here on the carbon footprint of inhalers are entirely concordant with other previous reports.

    Conflict of Interest:
    None declared.
  • Published on:
    Inhaler devices and global warming: Flawed arguments
    • Mark L Levy, Locum general practitioner Clinical Lead NRAD (2011-2014);Aerosol Drug ManagementImprovement Team (ADMIT),
    • Other Contributors:
      • Darragh Murnane, Professor of Asthma, Allergy & Respiratory Science,Professor of Pharmaceutics
      • Peter J Barnes, Margaret Turner-Warwick Professor of Medicine
      • Mark Sanders, Chief Technology Officer
      • Louise Fleming, Asthma UK Senior Clinical Fellow
      • Jane Scullion, Specialist Respiratory Nurse Consultant
      • Chris Corrigan, Professor of Asthma, Allergy & Respiratory Science
      • Omar S Usmani, Reader in Respiratory Medicine & Consultant Physician

    Mark L Levy,1,9 Darragh Murnane2, Peter J Barnes,3,9 Mark Sanders,4 Louise Fleming,5 Jane Scullion,6,9 Chris Corrigan,7,9 Omar S Usmani8,9

    1. Locum general practitioner, Clinical Lead NRAD (2011-2014)
    2. King’s College London Faculty of Life Sciences & Medicine, School of Immunology & Microbial Sciences ; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire
    3. National Heart & Lung Institute, Imperial College, London
    4. Clement Clarke international Ltd (CCI) and founder of online museum of inhaler devices,
    5. Imperial College, London and the Royal Brompton and Harefield, NHS Foundation Trust
    6. University Hospitals of Leicester
    7. King’s College London Faculty of Life Sciences & Medicine, School of Immunology & Microbial Sciences
    8. Imperial College London & Royal Brompton Hospital
    9. Aerosol Drug ManagementImprovement Team (ADMIT),

    In an attempt to address issues related to global warming contributed to by the use of pressurised, metered-dose inhalers (pMDIs), Wilkinson et al (1) have succeeded in generating a great deal of negative, potentially harmful media interest for patients who currently rely on these devices. They analysed the potential impact of switching therapy from pMDIs to dry powder inhalers (DPIs) in terms of both c...

    Show More
    Conflict of Interest:
    MLL Reports : consultancy /advisory board fees from National Services for Health Improvement, Clement Clarke International ,AstraZeneca, Orion,Trudell, Boeringer Ingelheim, Conzorcio Futuro In Ricerca, Novartis Pharmaceuticals, GLaxo Smith Klein , TEVA. Speaker fees from Teva, AstraZeneca, Chiesi, Orion, Menarini,
    Travel reimbursement for attending meetings from GINA, outside the submitted work.
    DM reports: Director of Fluid Pharmaceuticals, Deputy Director of EPSRC Centre for Doctoral Training in Aerosol Science, has received research funding or support from Astra Zeneca, Bespak, Cheisi, Clement Clarke International, GlaxoSmithKline, HarroHoffliger, Intertek Melbourn, Teva, Team Consulting, Malvern Panalytical, Zeiss, 3M Ltd., has received consultancy fees, speaker’s fees or hospitality from Adare Pharmaceuticals, DDL/Aerosol Society, Inhalation Asia, MedPharm Ltd. Talipharma Ltd., AstraZeneca, RDD.
    PB reports: Research funding from AstraZeneca and Boehringer-Ingelheim; scientific advisory boards/consultancies from AstraZeneca, Boehringer-Ingelheim, Novartis, Pieris, speaker fees from AstraZeneca Boehringer-Ingelheim, Chiesi, Menarini, Novartis, Teva.
    MS reports: CCI has received funding payments in respect of inhaler training development from an Innovate UK grant awarded to Clin-e-cal. CCI has supplied inhaler training tools to GSK, Astra Zeneca, Boehringer Ingelheim, Teva, Menarini, Mundipharma, Napp, Chiesi, Novartis, Orion and Mylan.
    LF is an Asthma UK Senior Clinical Fellow. She reports fees for expert consultation and speakers fees from Astra Zeneca, GSK, Novartis, Teva, Boehringer Ingelheim, Respiri and Sanofi paid direct to her institution and outside of the submitted work
    JS: Director of Education for UKIG, ADMIT member I have received support or honoraria from Association of Respiratory Nurse Specialists, AstraZeneca, Boehringer Ingelheim, Chiesi, MIMS, Napp Pharmaceuticals, Mundipharma,
    Pfizer, Novartis, Primary Care Respiratory Society, NIP, & Haymarket Medical
    CC reports no conflicts.
    OSU has received industry to academic funding from Boehringer Ingelheim, Chiesi, Edmond Pharma, GlaxoSmithKline, and Mundipharma International, and has received consultancy or speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Edmond Pharma, GlaxoSmithKline, NAPP, Novartis, Mundipharma International, Pearl Therapeutics, Roche, Sandoz, Takeda, Trudell Medical, UCB, and Vectura.
  • Published on:
    Key reference unavailable

    Probably the most important reference cannot be reached, number 23:

    Attempting to follow it gives the message: "Sorry - we can't find the page you are looking for"

    This is the reference which provides the justification for what seems to be the extremely high carbon footprint for each inhaler. Without this, it is difficult to have any faith in the conclusions of this paper.

    In general, it is bad practice to provide a citation to a non-permanent web resource.

    Conflict of Interest:
    None declared.