Are Inhalers a Major Source of Pollution?

Asthma is a chronic airway condition that triggers wheezing, shortness of breath and coughing. Those who have asthma may have symptoms ranging from mild to severe; these may occur every day or just on occasion. For many people, asthma begins in childhood and becomes a lifelong condition.

The goal of conventional medicine is to manage the symptoms, called asthma attacks. The Centers for Disease Control and Prevention says 7.9% of Americans are diagnosed with asthma.¹ Traditional treatment aimed at managing symptoms is realistically only a stopgap measure to help individuals engage in their everyday activities.

The type of treatment will usually depend upon age, severity and response to the options. One treatment commonly prescribed is a metered dose inhaler (MDI), also called a puffer, which is a pressurized canister designed to fit into a mouthpiece.²

How many times and how often you use the inhaler will depend upon what medication the device is delivering. The device measures the amount of medication in each puff and delivers it using a chemical propellant to help deliver it to your lungs.

Metered Dose Inhalers: A Measurable Source of Air Pollution

A research team from Cambridge University was led by Dr. Alexander Wilkinson who acknowledges inhalers are a lifeline for those who have breathing problems.³ Wilkinson serves as a respiratory consultant for the National Health Service (NHS) of England.

He and his team conducted prescription data in England during 2017⁴ to measure the effect MDI devices have on the environment. The types of inhalers were separated into categories based on the mechanism of action.

Data on the carbon footprint of inhalers from other scientific publications were reviewed, as well as independently certified reports. The data analysis revealed a potential reduction in financial and environmental cost. Replacing 10% of MDI inhalers using hydrofluoroalkanes (HFAs) with dry powder inhalers (DPI) delivering less expensive medication in the same category, could reduce drug cost in England by £8.2 million ($10.5 million) each year.

Additionally, using the same percentage of MDI to DPI switch, England could save 58,000 tons of carbon dioxide emissions every year affecting global warming. This is the same amount of air pollution 180,000 cars make driving 400 miles.⁵ Just five doses from one inhaler emits as much as one car driving 9 miles; most MDI canisters contain 100 doses. The researchers concluded:

"Substantial carbon savings can be made by using small volume HFA134a MDIs, in preference to large volume HFA134a MDIs, or those containing HFA227ea as a propellant."

England Identifies MDI as a Carbon Hotspot

According to England's House of Commons Environmental Audit Committee,⁶ most MDIs use the HFA134a propellant with a global warming potential (GWP) of 1,480. The NHS has identified MDIs as a "carbon hotspot."

The MDI is currently exempt from the EU's regulations. Although the HFA MDI inhaler is the most popular in England and the U.S., in most cases the DPI is prescribed in other countries, such as Sweden. GlaxoSmithKline told the House of Commons Audit Committee: "It is not just Sweden; it is across most of Europe that the dry powder inhaler is the predominant inhaler."

Health authorities in England have consistently balked at switching to DPI devices, citing cost as a major obstacle.⁷ But the researchers demonstrated a cost reduction when less expensive and equally effective medication was used in the green inhaler devices. Wilkinson talked about the results of the analysis, saying:⁸

"The gases within these canisters are such powerful greenhouse gases that they can contribute significantly to an individual's carbon footprint and if you are using one or two of these inhalers every month, then that can really add up to hundreds of kilos of carbon dioxide equivalent over the course of a year …"

This is not the first time propellants in MDI inhalers were removed when it was discovered they were dangerous. In 2008, the FDA⁹ banned the use of chlorofluorocarbons (CFCs) in albuterol inhalers due to U.S. participation in the International Montreal Protocol on Substances that Deplete the Ozone Layer. They were replaced with HFAs, another harmful chemical propellant.

Researchers Call for Alternative Treatments

Another scientist on the research team, Dr James Smith, consultant in public health at Cambridge University, is concerned for those who will be impacted by the threat to health and speaks to the small changes that may have a big impact, saying:¹⁰

"Climate change is a huge and present threat to health that will disproportionately impact the poorest and most vulnerable on the planet, including people with pre-existing lung disease. Our study shows switching to inhalers which are better for the environment could help individuals, and the NHS as a whole, reduce their impact on the climate significantly."

The research team are calling for exploration into environmentally friendly inhalers to help treat those who have asthma.¹¹ The data showed air pollution released from MDI devices produce an estimated 3.9% of the carbon footprint produced by medical devices and treatments prescribed by the NHS.

The scientists concluded if the Environmental Audit Committee's target of switching 50% of all inhalers to those having a low GWP by 2022 is achieved, it could reduce carbon emissions by 288,000 tons every year:¹²

"Switching to low GWP inhalers can be achieved while making financial savings in terms of drug costs. Patients, prescribers and guideline authors should carefully consider the carbon footprint of these inhalers and where they are likely to be equally effective, prioritise low GWP inhalers."

Make Each Puff Count

Using an MDI appropriately is important for both the environment and to inhale the medication. With each puff the propellant carries the medicine into your lungs. Wilkinson talks about the importance of using good technique, saying:¹³

"It's really important that we use these inhalers wisely, that patients have good technique and they have their technique assessed so we can really make sure every puff counts."

In addition to using the MDI device, you may also be prescribed a spacer or chamber to hold the ejected medication in a tube for a few seconds.¹⁴ This means you don't have to coordinate breathing in and compressing the canister at the same time. Spacers help reduce the risk of side effects when medication is deposited along your vocal cords or you don't receive enough medication.

Spacers use different designs and work with different types of MDIs. Some whistle to let you know you're inhaling too fast, some can be washed in the dishwasher and others must be hand washed. It is also important to keep track of the number of puffs you use for each canister. Many come with a dose counter, but some don't.

The label on the MDI will tell you how many puffs are in each canister. Keep a record of how many you've used since even if you see spray come out, it does not mean there is still medicine left in the canister. Wilkinson also points out once the canister is finished, it is important to get rid of it properly.¹⁵

The spray that comes out even when there's no medication in the canister is the propellant. These greenhouse gases need to be disposed of appropriately. He recommends taking your MDI canister back to the pharmacy for proper disposal.

How Many Suffer With Asthma?

There are currently 5.4 million adults and children in the U.K. who receive treatment for asthma.¹⁶ The study team concluded that changing just 10% of the MDI devices in this population could significantly reduce carbon emissions.

According to the World Health Organization, 235 million people around the world suffer from asthma and it is one of the most common chronic diseases in children.¹⁷ In the U.S., the 7.9% dealing with asthma adds up to 26 million people.¹⁸

In real numbers, the U.S. has 4.8 times the number of people with asthma as England. This means the real number of MDI devices in use in the U.S. is also higher. While GlaxoSmithKline reports other countries are switching to greener alternatives, the U.S. and the U.K are not included on the list.

Natural Options May Reduce Reliance on Medication

You may make a significant difference in reducing air pollution by investigating alternative methods of treatment — both medicinal and natural. It is important to remember that the underlying concepts of Western medicine are reactionary. In other words, physicians wait until there is a problem and then prescribe drugs to treat it.

These drugs often come with side effects that may trigger another prescription to control the side effects of the first. While there is a time for medication, it's important to first offer your body every chance to control the condition naturally.

In other words, by supporting your body's natural functions, you may be able to reduce or eliminate your reliance on medications. For instance, an imbalance of omega-3 and omega-6 fatty acids increases the likelihood you'll experience an asthma attack. Researchers from Johns Hopkins found children with asthma who had a higher intake of omega-3 appeared to be more resilient, with fewer symptoms when exposed to air pollution.

Vitamin D also plays a crucial role in your body's ability to fight inflammation, a root cause of many chronic diseases. As I've written before and which has since gathered more research evidence,¹⁹ optimal levels of vitamin D reduces the risk of asthma exacerbations.

Homeopathic treatments offer another treatment as practitioners focus on the whole-body function and do not treat only an individual symptom. Historically, those treated in homeopathic hospitals suffered a death rate one half to one-eighth of those treated in conventional medical hospitals.

In fact, during the 1849 cholera epidemic, Cincinnati homeopaths were so successful that published data show 3% of their patient population died while 48% to 60% of those under traditional medical treatment died. Homeopathic remedies are essentially nanomedicines as they operate on the premise that the more diluted the remedy, the more effective it becomes.

In addition, there are far fewer side effects and adverse reactions. Seek out a homeopathic professional who can help identify a remedy specific to your condition to reduce or eliminate breathing difficulties associated with asthma. Read more about the history of homeopathy and treatments for asthma in my past article, "Homeopathy for Asthma."