{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T13:35:35Z","timestamp":1767792935022,"version":"3.49.0"},"reference-count":45,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2025,10,22]],"date-time":"2025-10-22T00:00:00Z","timestamp":1761091200000},"content-version":"unspecified","delay-in-days":21,"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":[[2025,9,22]]},"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Inhalers are essential for managing asthma and chronic obstructive pulmonary disease; however, their environmental effects vary significantly. Pressurised metered-dose inhalers (pMDIs) contain potent greenhouse gases (GHGs), resulting in a much higher carbon footprint (CF) than non-propellant inhalers (NPIs). Consequently, reducing the use of pMDIs is seen as an important contribution to reduce the healthcare sector\u2019s effect on climate change. This study analyses inhaler dispensing trends in Germany, estimates their resulting CF and quantifies the potential GHG savings from increased NPI use.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Dispensing data at the expense of statutory health insurances, covering nearly 90% of the German population, were analysed from 2013 to 2022 across three age groups. Annual dispensing shares and CF estimates based on life cycle assessment-derived CF values were calculated for four inhaler types: pMDIs with hydrofluorocarbon (HFC)-134a, pMDIs with HFC-227ea, dry powder inhalers (DPIs), and soft mist inhalers (SMIs). Two scenario calculations estimated the potential GHG savings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Between 2013 and 2022, the total number of dispensed defined daily doses of inhalers increased by 14%, with no significant shift towards lower-emission inhalers (2013, 55% NPIs; 2022, 52% NPIs). Consequently, the total CF increased from 459 kilotonnes of carbon dioxide equivalent (kt CO\n                      <jats:sub>2<\/jats:sub>\n                      eq) in 2013 to 525 kt CO\n                      <jats:sub>2<\/jats:sub>\n                      eq in 2022 (+14%). More than 95% of the inhaler-related CF was attributable to pMDIs. A GHG-saving scenario assuming 85% NPI use among patients aged 10\u201379 years projected an annual CF reduction of 55% (288 kt CO\n                      <jats:sub>2<\/jats:sub>\n                      eq).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Despite climate neutrality goals, inhaler-related CF has continued to rise because of stable pMDI usage rates. The substantial potential for GHG reduction highlights the necessity and feasibility of a sustainable change in clinical prescription practice. Our insights could support the promotion of climate-friendly inhalers across other European countries with similar prescription patterns.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjresp-2025-003329","type":"journal-article","created":{"date-parts":[[2025,10,23]],"date-time":"2025-10-23T07:00:12Z","timestamp":1761202812000},"page":"e003329","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Inhaler use and their carbon footprint in Germany: a 10-year analysis (2013\u20132022)"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-4147-6838","authenticated-orcid":false,"given":"Sarah","family":"Blau","sequence":"first","affiliation":[{"name":"Medical Faculty, RWTH Aachen University, Institute for Digitalization and General Medicine, Center for Rare Diseases Aachen (ZSEA), Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martin","family":"M\u00fccke","sequence":"additional","affiliation":[{"name":"Medical Faculty, RWTH Aachen University, Institute for Digitalization and General Medicine, Center for Rare Diseases Aachen (ZSEA), Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michaela","family":"Hesse","sequence":"additional","affiliation":[{"name":"Medical Faculty, RWTH Aachen University, Institute for Digitalization and General Medicine, Center for Rare Diseases Aachen (ZSEA), Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julia","family":"Sellin","sequence":"additional","affiliation":[{"name":"Medical Faculty, RWTH Aachen University, Institute for Digitalization and General Medicine, Center for Rare Diseases Aachen (ZSEA), Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1810-090X","authenticated-orcid":false,"given":"Gabriele","family":"Gradl","sequence":"additional","affiliation":[{"name":"German Institute for Drug Use Evaluation (DAPI), Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5876-7322","authenticated-orcid":false,"given":"Martin","family":"Schulz","sequence":"additional","affiliation":[{"name":"German Institute for Drug Use Evaluation (DAPI), Berlin, Germany"},{"name":"Institute of Pharmacy, Freie Universitat Berlin, Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-9791-3920","authenticated-orcid":false,"given":"G\u00fclay","family":"Ate\u015f","sequence":"additional","affiliation":[{"name":"Medical Faculty, RWTH Aachen University, Institute for Digitalization and General Medicine, Center for Rare Diseases Aachen (ZSEA), Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,10,22]]},"reference":[{"key":"2026010701515244000_12.1.e003329.1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)32594-7"},{"key":"2026010701515244000_12.1.e003329.2","unstructured":"Health Care Without Harm . Health care\u2019s climate footprint. 2019. Available: https:\/\/noharm-global.org\/documents\/health-care-climate-footprint-report [Accessed 15 Jan 2024]."},{"key":"2026010701515244000_12.1.e003329.3","unstructured":"Pichler P-P , Jaccard IS , Hanewinkel L , et al . Evidenzbasis treibhausgasemissionen des deutschen gesundheitswesens. GermanHealthCFP; 2022. Available: https:\/\/www.bundesgesundheitsministerium.de\/fileadmin\/Dateien\/5_Publikationen\/Gesundheit\/Berichte\/GermanHealthCFP_Sachbericht.pdf [Accessed 05 Feb 2024]."},{"key":"2026010701515244000_12.1.e003329.4","doi-asserted-by":"publisher","DOI":"10.1016\/S2542-5196(20)30271-0"},{"key":"2026010701515244000_12.1.e003329.5","doi-asserted-by":"crossref","unstructured":"Traidl-Hoffmann C , Schulz C , Herrmann M , et al . Planetary Health - Klima, Umwelt Gesundheit Im Anthropoz\u00e4n. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft, 2021.","DOI":"10.32745\/9783954666737"},{"key":"2026010701515244000_12.1.e003329.6","unstructured":"Institute for Health Metrics and Evaluation . GBD compare. Available: https:\/\/vizhub.healthdata.org\/gbd-compare\/ [Accessed 11 Jan 2024]."},{"key":"2026010701515244000_12.1.e003329.7","unstructured":"Bundesverband der Arzneimittel-Hersteller . Der arzneimittelmarkt in deutschland. 2022. Available: https:\/\/www.bah-bonn.de\/publikationen\/zahlen-fakten\/ [Accessed 05 Mar 2024]."},{"key":"2026010701515244000_12.1.e003329.8","unstructured":"WIdO . Der gkv-arzneimittelmarkt: klassifikation, methodik und ergebnisse 2022. 2022. Available: https:\/\/www.wido.de\/fileadmin\/Dateien\/Dokumente\/Forschung_Projekte\/Arzneimittel\/wido_arz_gkv-arzneimittelmarkt_klassifikation_methodik_ergebnisse_2022.pdf [Accessed 25 Jan 2024]."},{"key":"2026010701515244000_12.1.e003329.9","unstructured":"United Nations Environment Programme . Montreal protocol on substances that deplete the ozone layer: medical and chemical technical options committee 2018 assessment. 2018. Available: https:\/\/ozone.unep.org\/sites\/default\/files\/2019-04\/MCTOC-Assessment-Report-2018.pdf [Accessed 08 Apr 2024]."},{"key":"2026010701515244000_12.1.e003329.10","unstructured":"United Nations Environment Programme . About montreal protocol. 2018. Available: http:\/\/www.unep.org\/ozonaction\/who-we-are\/about-montreal-protocol [Accessed 11 Jan 2024]."},{"key":"2026010701515244000_12.1.e003329.11","unstructured":"IPCC . Direct global warming potentials. 2023. Available: https:\/\/archive.ipcc.ch\/publications_and_data\/ar4\/wg1\/en\/ch2s2-10-2.html [Accessed 10 Dec 2023]."},{"key":"2026010701515244000_12.1.e003329.12","unstructured":"Schmiemann G , D\u00f6rks M , Grah C . Klimabewusste Verordnung von Inhalativa: S2k-Leitlinie, 2024. Available: https:\/\/register.awmf.org\/assets\/guidelines\/053-059l_S2k_Klimabewusste-Verordnung-Inhalativa_2024-02.pdf [Accessed 30 Mar 2024]."},{"key":"2026010701515244000_12.1.e003329.13","first-page":"321","article-title":"Reduction of greenhouse gas emissions by inhaler choice in the therapy of asthma and COPD patients","volume":"76","author":"Bickhardt","year":"2022","journal-title":"Pneumologie"},{"key":"2026010701515244000_12.1.e003329.14","doi-asserted-by":"crossref","DOI":"10.1002\/prp2.675","article-title":"Climate change in healthcare: Exploring the potential role of inhaler prescribing","volume":"8","author":"Starup-Hansen","year":"2020","journal-title":"Pharmacol Res Perspect"},{"key":"2026010701515244000_12.1.e003329.15","article-title":"Change from mdi to dpi in asthma: effects on climate emissions and disease control","volume":"58(suppl 65)","author":"Woodcock","year":"2021","journal-title":"Eur Respir J"},{"key":"2026010701515244000_12.1.e003329.16","doi-asserted-by":"publisher","DOI":"10.1136\/thoraxjnl-2021-218088"},{"key":"2026010701515244000_12.1.e003329.17","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2018-028763","article-title":"Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England","volume":"9","author":"Wilkinson","year":"2019","journal-title":"BMJ Open"},{"key":"2026010701515244000_12.1.e003329.18","doi-asserted-by":"crossref","first-page":"3016","DOI":"10.1111\/bcp.15135","article-title":"The environmental impact of inhalers for asthma: A green challenge and a golden opportunity","volume":"88","author":"Wilkinson","year":"2022","journal-title":"Brit J Clinical Pharma"},{"key":"2026010701515244000_12.1.e003329.19","doi-asserted-by":"crossref","DOI":"10.1183\/13993003.02106-2021","article-title":"The environmental impact of inhaled therapy: making informed treatment choices","volume":"60","author":"Woodcock","year":"2022","journal-title":"Eur Respir J"},{"key":"2026010701515244000_12.1.e003329.20","doi-asserted-by":"crossref","DOI":"10.1136\/bmjresp-2023-001782","article-title":"Thoughtful prescription of inhaled medication has the potential to reduce inhaler-related greenhouse gas emissions by 85","volume":"11","author":"Vartiainen","year":"2024","journal-title":"BMJ Open Respir Res"},{"key":"2026010701515244000_12.1.e003329.21","doi-asserted-by":"publisher","DOI":"10.3122\/jabfm.2022.220292R2"},{"key":"2026010701515244000_12.1.e003329.22","article-title":"Development of a shared decision-making tool to support patients and their healthcare provider in choosing the best inhaler device","volume":"52(suppl 62)","author":"Metting","year":"2018","journal-title":"Eur Respir J"},{"key":"2026010701515244000_12.1.e003329.23","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-055546","article-title":"Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data","volume":"12","author":"Ten Have","year":"2022","journal-title":"BMJ Open"},{"key":"2026010701515244000_12.1.e003329.24","doi-asserted-by":"crossref","DOI":"10.1136\/bmjresp-2021-001071","article-title":"Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries","volume":"8","author":"Pernigotti","year":"2021","journal-title":"BMJ Open Respir Res"},{"key":"2026010701515244000_12.1.e003329.25","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1177\/17151635241268299","article-title":"Environmentally sustainable opportunities for health systems: Metered-dose inhaler prescribing, dispensing, use and waste at a tertiary academic centre","volume":"157","author":"Caron","year":"2024","journal-title":"Can Pharm J (Ott)"},{"key":"2026010701515244000_12.1.e003329.26","unstructured":"NHS England . Green plan guidance. Available: https:\/\/www.england.nhs.uk\/long-read\/green-plan-guidance\/ [Accessed 07 Sep 2025]."},{"key":"2026010701515244000_12.1.e003329.27","unstructured":"South East London ICS . Inhaler return and recycling. Available: https:\/\/www.selondonics.org\/our-residents\/your-health\/local-nhs-services\/inhaler-return-and-recycling\/ [Accessed 07 Sep 2025]."},{"key":"2026010701515244000_12.1.e003329.28","unstructured":"The National Return & Disposal of Unwanted Medicines . About return unwanted medicines. Available: https:\/\/returnmed.com.au\/info\/about-return-unwanted-medicines\/ [Accessed 07 Sep 2025]."},{"key":"2026010701515244000_12.1.e003329.29","doi-asserted-by":"publisher","DOI":"10.1136\/thoraxjnl-2019-213744"},{"key":"2026010701515244000_12.1.e003329.30","unstructured":"UK Parliament . UK Progress on reducing F-gas Emissions, 2018. Available: https:\/\/publications.parliament.uk\/pa\/cm201719\/cmselect\/cmenvaud\/469\/46905.htm#_idTextAnchor015 [Accessed 11 Jan 2024]."},{"key":"2026010701515244000_12.1.e003329.31","doi-asserted-by":"crossref","first-page":"903","DOI":"10.1038\/s41371-020-00425-z","article-title":"Impact of angiotensin receptor blocker product recalls on antihypertensive prescribing in Germany","volume":"35","author":"Rudolph","year":"2021","journal-title":"J Hum Hypertens"},{"key":"2026010701515244000_12.1.e003329.32","unstructured":"Federal Statistical Office of Germany . Bev\u00f6lkerungsstand. Available: https:\/\/www.destatis.de\/DE\/Themen\/Gesellschaft-Umwelt\/Bevoelkerung\/Bevoelkerungsstand\/Tabellen\/liste-zensus-geschlecht-staatsangehoerigkeit.html [Accessed 08 Apr 2024]."},{"key":"2026010701515244000_12.1.e003329.33","unstructured":"Federal Ministry of Health of Germany . Mitglieder und versicherte der gesetzlichen krankenversicherung (gkv). Available: https:\/\/www.bundesgesundheitsministerium.de\/themen\/krankenversicherung\/zahlen-und-fakten-zur-krankenversicherung\/mitglieder-und-versicherte [Accessed 08 Apr 2024]."},{"key":"2026010701515244000_12.1.e003329.34","doi-asserted-by":"crossref","first-page":"2487","DOI":"10.1007\/s12325-019-01028-y","article-title":"Reduced Environmental Impact of the Reusable Respimat(\u00ae) Soft Mist\u2122 Inhaler Compared with Pressurised Metered-Dose Inhalers","volume":"36","author":"H\u00e4nsel","year":"2019","journal-title":"Adv Ther"},{"key":"2026010701515244000_12.1.e003329.35","doi-asserted-by":"publisher","DOI":"10.1002\/jgf2.622"},{"key":"2026010701515244000_12.1.e003329.36","unstructured":"Federal Statistical Office of Germany . 3% der j\u00e4hrlichen co2-emissionen werden netto vom wald absorbiert. 2021. Available: https:\/\/www.destatis.de\/DE\/Presse\/Pressemitteilungen\/Zahl-der-Woche\/2021\/PD21_40_p002.html [Accessed 19 Apr 2024]."},{"key":"2026010701515244000_12.1.e003329.37","unstructured":"German Federal Environment Agency (UBA) . UBA carbon calculator. Available: https:\/\/uba.co2-rechner.de\/en_GB\/ [Accessed 20 Apr 2024]."},{"key":"2026010701515244000_12.1.e003329.38","unstructured":"DEGAM . Positionspapier der ag klimawandel und gesundheit der degam. 2020. Available: https:\/\/www.degam.de\/files\/inhalt\/pdf\/positionspapiere_stellungnahmen\/positionspapiere-altes-verzeichnis\/Positionspapier_Klimawandel_Gesundheit_final.pdf [Accessed 10 Dec 2023]."},{"key":"2026010701515244000_12.1.e003329.39","doi-asserted-by":"crossref","DOI":"10.1183\/23120541.00455-2024","article-title":"Dry-powder inhaler use in primary school-aged children with asthma: a systematic review","volume":"10","author":"Kuek","year":"2024","journal-title":"ERJ Open Res"},{"key":"2026010701515244000_12.1.e003329.40","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2466-9-1","article-title":"Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control","volume":"9","author":"Thomas","year":"2009","journal-title":"BMC Pulm Med"},{"key":"2026010701515244000_12.1.e003329.41","doi-asserted-by":"publisher","DOI":"10.1136\/thorax-2023-220259"},{"key":"2026010701515244000_12.1.e003329.42","unstructured":"German Medical Association . (Model) professional code for physicians in germany. 2018. Available: https:\/\/www.bundesaerztekammer.de\/fileadmin\/user_upload\/_old-files\/downloads\/pdf-Ordner\/MBO\/MBO-AE_EN_2018.pdf [Accessed 20 Mar 2024]."},{"key":"2026010701515244000_12.1.e003329.43","unstructured":"WHO . Communicating on climate change and health: Toolkit for health professionals, 2024. Available: https:\/\/www.who.int\/publications\/i\/item\/9789240090224 [Accessed 17 Apr 2024]."},{"key":"2026010701515244000_12.1.e003329.44","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclepro.2019.117733"},{"key":"2026010701515244000_12.1.e003329.45","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"}],"container-title":["BMJ Open Respiratory Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjresp-2025-003329","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T09:53:20Z","timestamp":1767779600000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopenrespres.bmj.com\/lookup\/doi\/10.1136\/bmjresp-2025-003329"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,10,22]]},"published-print":{"date-parts":[[2025,10]]}},"alternative-id":["10.1136\/bmjresp-2025-003329"],"URL":"https:\/\/doi.org\/10.1136\/bmjresp-2025-003329","relation":{},"ISSN":["2052-4439"],"issn-type":[{"value":"2052-4439","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10]]}}}