Resource Spotlight: Environmental sustainability of Inhalers

May 16, 2023
Written by Layne Liberty
This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at


Asthma and chronic obstructive pulmonary disease (COPD) are two of the most common respiratory diseases with 3.8 million Canadians over the age of one living with asthma and two million living with COPD.1 Both conditions require the use of inhaler therapies to reduce morbidity and mortality.2 Many medications for these conditions are delivered using a pressurized metered dose inhaler (pMDI) which contain potent greenhouse gases (GHG) called hydrofluoroalkanes (HFA), or also known as hydrofluorocarbons (HFC).2 The GHG emitted from pMDI devices contribute to the carbon footprint of healthcare, which is estimated to be responsible for 4.6% of Canada’s total GHG emissions (equivalent to over thirty-three million tonnes of carbon dioxide equivalents).3  Other options for inhaled medications include dry powder inhalers (DPI) and soft mist inhalers (SMI), which both do not contain HFCs, and therefore, have a lower carbon footprint.2 While reducing the use of pMDIs may have positive impacts on the environment, changing therapies has implications for patients; thus, considerations such as inspiratory flow rate, handling capabilities, individual preference and financial constraints must be kept in mind. This resource spotlight aims to provide awareness, evidence and education about the environmental impact of inhalers to help pharmacists begin implementing environmentally sustainable practices. To learn more about the environmental impact of inhalers, check out the Canadian Society of Hospital Pharmacist (CSHP) recent Clinical Pearl article here

External Resorces

Unless otherwise noted, the Canadian Society of Hospital Pharmacists (CSHP) does not endorse or imply endorsement of the resources provided here. These resources are provided without warranty of any kind, either expressed or implied. It is the responsibility of the user of the resource to judge its suitability for his or her particular purpose within the context of his or her practice and the applicable legislative framework. In no event shall CSHP or any persons involved in providing the resource be liable for damages arising from its use. Resources are free unless otherwise indicated.  

Canadian Resources

Creating A Sustainable Canadian Health System In A Climate Crisis (CASCADES) 

CASCADES is a national collaborative project supporting the transition to a net zero carbon emission and climate resilient Canadian health care system. The website has a repository of guides, patient friendly infographics and tools regarding environmentally sustainable prescribing of inhaled therapies, such as: 

  1. The Inhaler Primer Series provides a detailed overview of the environmental impact of inhalers and outlines options to mitigate and reduce the carbon footprint of inhalers
  2. The Inhaler Playbook provides a guide to sustainable inhaler use in primary care including a prescribing pathway with considerations for switching to alternative therapies, patient education and disposal
  3. A detailed inhaler comparison chart that compares available inhalers in Canada by carbon footprint, cost prior to coverage and provincial and territorial coverage status to support ease of sustainable prescribing 
  4. A quick reference chart to support the switch to alternative low carbon footprint inhalers for adults 
  5. A webinar on the climate impact of inhalers that provides education on proper asthma diagnosis, current guidelines, appropriate patient specific inhaler prescribing and logical switches to lower carbon footprint inhalers 

Health Product Stewardship Association (HPSA) 

HPSA runs a free medication return program through community pharmacies in BC, Manitoba, Ontario and PEI. It provides guidance for community pharmacies on how to implement these programs and guidance to consumers on safe disposal practices. This program is not available for hospitals or long-term care facilities; however, it is a useful resource for hospital pharmacists to refer patients to when counselling on inhaler medications and discussing proper disposal practices.  

European Resources

National Institute For Health And Care Excellence (NICE) 
NICE provides guidance and develops evidence-based recommendations to support best practices for the National Health Services (NHS) in the United Kingdom (UK). NICE has published a patient decision aid to help healthcare professionals and patients with asthma choose an appropriate inhaler while also considering the carbon footprint of treatment. It provides answers to common questions about switching inhaler treatments and is meant to support the shared decision making between the patient (over 12 years old) and healthcare professional.

Prescribing Always Includes Consideration OfQuality, Innovation, Productivity And Prevention (PrescQIPP

PrescQIPP is a not-for-profit social enterprise with the aim of supporting quality prescribing in the NHS. PrescQIPP has a repository of information on Bulletin 295: Inhaler carbon footprint such as: 

  1. A guidance document that provides suggestions for inhaler optimisation and support for healthcare professionals to start or switch patients to low carbon footprint inhalers. It also provides education around the impact and importance of proper inhaler disposal.  
  2. A tool designed for patient understanding that compares the carbon footprint of inhalers using easy to understand symbols and visuals.

Inhaler Life Cycle Assessment  
A sustainability evidence review of Carbon Footprints and Life Cycle Assessments of Inhalers was published in 2022. This paper provides an overview of the carbon footprint of pMDIs, DPIs and SMIs from creation of the active primary ingredient (API) all the way to end of life and disposal phase. The results show that the carbon footprint varies depending on which DPI is used and that the carbon footprint from DPI and SMIs is primarily due to the API and manufacturing stages of the life cycle, while pMDI is from the use and end of life phase.  


  1. Public Health Agency of Canada. Report from the Canadian chronic disease surveillance system: asthma and chronic obstructive pulmonary disease (COPD) in Canada [Internet]. Ottawa: Government of Canada Publications; 2018. 61 p. Available from: 
  2. Pernigotti D, Stonham C, Panigone S, Sandri F, Ferri R, Unal Y et al Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries. BMJ Op Resp Res. 2021;8(1):1-11. Available from: doi: 10.1136/bmjresp-2021-001071 
  3. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLOS Medicine. 2018;15(7):1-16. Available from: