{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T13:35:14Z","timestamp":1767792914491,"version":"3.49.0"},"reference-count":16,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T00:00:00Z","timestamp":1750982400000},"content-version":"unspecified","delay-in-days":26,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Resp Res"],"accepted":{"date-parts":[[2025,6,13]]},"published-print":{"date-parts":[[2025,6]]},"abstract":"\n Introduction<\/jats:title>\n \n Inhalers for asthma and chronic obstructive pulmonary disease (COPD) are essential therapeutic interventions; however, they contribute significantly to healthcare-related CO\n 2<\/jats:sub>\n -equivalent (CO\n 2<\/jats:sub>\n eq) emissions, particularly currently used metered dose inhalers (MDIs), which use hydrofluoroalkane (HFA) propellants such as HFA-124a and HFA-227. This study quantifies the carbon footprint of inhaler utilisation in South Tyrol, Italy, and evaluates the potential CO\n 2<\/jats:sub>\n eq reductions achievable through the transition from MDIs to dry powder inhalers (DPIs).\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n This cross-sectional analysis used regional healthcare prescription data for inhalers dispensed in South Tyrol in 2021 and 2022, encompassing approximately 540\u2009000 inhabitants. CO\n 2<\/jats:sub>\n eq emissions were calculated based on HFA content in MDIs, employing established global warming potentials, while DPI emissions were estimated from current literature values.\n <\/jats:p>\n <\/jats:sec>\n \n Findings<\/jats:title>\n \n A total of 100\u2009778 inhalers were dispensed in 2021 (45 031 MDIs, 55\u2009747 DPIs) and 101\u2009334 in 2022 (49 711 MDIs, 51\u2009623 DPIs). MDIs were responsible for approximately 1000\u20131100 tonnes of CO\n 2<\/jats:sub>\n eq annually, whereas DPIs accounted for less than 55 tonnes. A transition to DPIs could potentially result in significant CO\n 2<\/jats:sub>\n eq reductions.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Usage of DPIs over currently used MDIs in patients who can use them could mitigate healthcare-associated global warming potential, providing a viable strategy for climate change mitigation in respiratory care. Development of low-global warming potential MDIs is a complementary strategy.<\/jats:p>\n <\/jats:sec>","DOI":"10.1136\/bmjresp-2024-002977","type":"journal-article","created":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T14:40:20Z","timestamp":1751035220000},"page":"e002977","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Comparing the CO\n 2<\/sub>\n emissions of metered dose inhalers and dry powder inhalers: a cross-sectional environmental impact analysis of asthma and COPD therapies in South Tyrol, Italy"],"prefix":"10.1136","volume":"12","author":[{"given":"Jonas","family":"Mairhofer","sequence":"first","affiliation":[{"name":"Institute of General Practice and Public Health, Claudiana Higher Provincial School of Health Professions, Bolzano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katia","family":"Sangermano","sequence":"additional","affiliation":[{"name":"Medical Directorate, Azienda Sanitaria dell\u2019Alto Adige, Bolzano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"G\u00fcnther","family":"Morandell","sequence":"additional","affiliation":[{"name":"Hospital Pharmacy Bolzano, Azienda Sanitaria dell\u2019Alto Adige, Bolzano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giuliano","family":"Piccoliori","sequence":"additional","affiliation":[{"name":"Institute of General Practice and Public Health, Claudiana Higher Provincial School of Health Professions, Bolzano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adolf","family":"Engl","sequence":"additional","affiliation":[{"name":"Institute of General Practice and Public Health, Claudiana Higher Provincial School of Health Professions, Bolzano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4639-8195","authenticated-orcid":false,"given":"Christian Josef","family":"Wiedermann","sequence":"additional","affiliation":[{"name":"Institute of General Practice and Public Health, Claudiana Higher Provincial School of Health Professions, Bolzano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,6,27]]},"reference":[{"key":"2026010701510607000_12.1.e002977.1","doi-asserted-by":"publisher","DOI":"10.1016\/S2213-2600(21)00511-7"},{"key":"2026010701510607000_12.1.e002977.2","unstructured":"Osservatorio Sanitario . Relazione Sanitaria 2022. Bolzano-Bozen: Provincia Autonoma di Bolzano-Alto Adige, 2024."},{"key":"2026010701510607000_12.1.e002977.3","doi-asserted-by":"crossref","DOI":"10.1038\/s41533-023-00346-7","article-title":"Effective respiratory management of asthma and COPD and the environmental impacts of inhalers","volume":"33","author":"Usmani","year":"2023","journal-title":"NPJ Prim Care Respir Med"},{"key":"2026010701510607000_12.1.e002977.4","doi-asserted-by":"crossref","unstructured":"Myhre G , Shindell D , Br\u00e9on F-M , et al . Anthropogenic and Natural Radiative Forcing. Climate Change 2013 - The Physical Science Basis. Cambridge University Press, 2014:659\u2013740.","DOI":"10.1017\/CBO9781107415324.018"},{"key":"2026010701510607000_12.1.e002977.5","doi-asserted-by":"crossref","DOI":"10.1136\/bmjresp-2020-000571","article-title":"Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment","volume":"7","author":"Panigone","year":"2020","journal-title":"BMJ Open Respir Res"},{"key":"2026010701510607000_12.1.e002977.6","doi-asserted-by":"publisher","DOI":"10.1136\/thoraxjnl-2019-213744"},{"key":"2026010701510607000_12.1.e002977.7","doi-asserted-by":"crossref","first-page":"427","DOI":"10.5603\/ARM.a2021.0092","article-title":"Impact of inhalers used in the treatment of respiratory diseases on global warming","volume":"89","author":"Emeryk","year":"2021","journal-title":"Adv Respir Med"},{"key":"2026010701510607000_12.1.e002977.8","doi-asserted-by":"publisher","DOI":"10.1136\/thoraxjnl-2021-218088"},{"key":"2026010701510607000_12.1.e002977.9","doi-asserted-by":"crossref","first-page":"1","DOI":"10.17925\/USPRD.2023.8.2.1","article-title":"The Excessive Carbon Footprint of Inhalers Used in Airway Disease and its Remedies","volume":"8","author":"D\u00e9sy","year":"2023","journal-title":"touchREVIEWS in Respiratory & Pulmonary Diseases"},{"key":"2026010701510607000_12.1.e002977.10","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1016\/j.chest.2024.06.3774","article-title":"Patient and Provider Perspectives Driving Inhaler Choice: Optimizing Sustainable Health Care","volume":"166","author":"Lough","year":"2024","journal-title":"Chest"},{"key":"2026010701510607000_12.1.e002977.11","doi-asserted-by":"crossref","DOI":"10.1093\/ijpp\/riae013.043","article-title":"Patients\u2019 views and behaviours in relation to asthma inhalers use and their impact on environmental sustainability: a cross-sectional survey study","volume":"32","author":"Herrera","year":"2024","journal-title":"Int J Pharm Pract"},{"key":"2026010701510607000_12.1.e002977.12","doi-asserted-by":"crossref","first-page":"46","DOI":"10.36469\/jheor.2021.26113","article-title":"Health-care Resource Requirements and Potential Financial Consequences of an Environmentally Driven Switch in Respiratory Inhaler Use in England","volume":"8","author":"Attar-Zadeh","year":"2021","journal-title":"J Health Econ Outcomes Res"},{"key":"2026010701510607000_12.1.e002977.13","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2024.49234","article-title":"Implementation of a Metered-Dose Inhaler to Dry-Powder Inhaler National Formulary Transition","volume":"7","author":"Rabin","year":"2024","journal-title":"JAMA Netw Open"},{"key":"2026010701510607000_12.1.e002977.14","doi-asserted-by":"crossref","DOI":"10.1183\/13993003.02760-2021","article-title":"The carbon footprint of respiratory treatments in Europe and Canada: an observational study from the CARBON programme","volume":"60","author":"Janson","year":"2022","journal-title":"Eur Respir J"},{"key":"2026010701510607000_12.1.e002977.15","doi-asserted-by":"crossref","DOI":"10.1038\/s41533-023-00327-w","article-title":"Understanding the feasibility and environmental effectiveness of a pilot postal inhaler recovery and recycling scheme","volume":"33","author":"Murphy","year":"2023","journal-title":"NPJ Prim Care Respir Med"},{"key":"2026010701510607000_12.1.e002977.16","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclepro.2019.117733"}],"container-title":["BMJ Open Respiratory Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjresp-2024-002977","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T09:52:15Z","timestamp":1767779535000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopenrespres.bmj.com\/lookup\/doi\/10.1136\/bmjresp-2024-002977"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6]]},"references-count":16,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,6,27]]},"published-print":{"date-parts":[[2025,6]]}},"alternative-id":["10.1136\/bmjresp-2024-002977"],"URL":"https:\/\/doi.org\/10.1136\/bmjresp-2024-002977","relation":{},"ISSN":["2052-4439"],"issn-type":[{"value":"2052-4439","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6]]}}}