During an asthma check-up at Brigham and Women's Hospital in Boston, Joel Rubinstein gets a surprising pitch — for the planet, as well as his health.
His pulmonologist, Dr. Miguel Divo, explains that the familiar boot-shaped respiratory inhalers, which represent nearly 90% of the U.S. market for asthma medication, save lives but also contribute to climate change.
Each puff from that type of inhaler releases a hydrofluorocarbon gas that is 1,430 to 3,000 times as powerful as the most commonly known greenhouse gas, carbon dioxide.
"That absolutely never occurred to me," says Rubinstein, a retired psychiatrist. "Especially, I mean, these are little, teeny things."
Divo has begun offering a more eco-friendly option to some patients with asthma and other lung diseases: a handheld plastic disk about the size and shape of a hockey puck that contains powdered medicine. Patients suck the powder into their lungs — no puff of gas required, and no greenhouse gas emissions.
"You have the same medications, two different delivery systems," Divo says.
Climate impact of metered-dose inhalers vs. cars
Patients in the United States are prescribed roughly 144 million of what doctors call metered-dose inhalers each year, according to the most recently available data published in 2020.
The cumulative amount of gas released is the equivalent of driving half a million gas-powered cars for a year. So, the benefits of moving to dry powder inhalers from gas inhalers could add up.
Hydrofluorocarbon gas contributes to climate change, which is creating more wildfire smoke, other types of air pollution, and longer allergy seasons. These conditions can make breathing more difficult — especially for people with asthma and chronic obstructive pulmonary disease, or COPD — and increase the use of inhalers.
Divo is one of a small but growing number of U.S. physicians determined to reverse what they see as an unhealthy cycle.
"There is only one planet and one human race," Divo says. "We are creating our own problems and we need to do something."
Divo is working with patients like Rubinstein who may be willing to switch to dry powder inhalers.
At first, Rubinstein said no to the idea because the powder inhaler would have been more expensive. Then his insurer increased the copay on the metered-dose inhaler, so Rubinstein decided to try the dry powder.
"For me, price is a big thing," says Rubinstein, who has tracked health care and pharmaceutical spending in his professional roles for years.
Inhaling the medicine using more of his own lung power was an adjustment, he says. "The powder is a very strange thing, to blow powder into your mouth and lungs."
But Rubinstein found the new inhaler works and his asthma is under control.
The environmental benefits of dry powder inhalers
A recent study of some patients in the United Kingdom who use dry powder inhalers found that they have better asthma control while reducing greenhouse gas emissions. In Sweden, where the vast majority of patients use dry powder inhalers, rates of severe asthma are lower than in the United States.
Rubinstein is one of a small number of U.S. patients who have made the transition. Among Divo's patients, only about a quarter would even consider switching.
The reasons vary, Divo explains. Dry powder inhalers are often more expensive than gas propellant inhalers. For some, dry powder isn't a good option because not all asthma or COPD sufferers can get their medications in this form. And dry powder inhalers aren't recommended for young children or elderly patients with diminished lung strength.
Some patients using dry powder inhalers worry that without the familiar noise that accompanies the propelled spray, they may not be receiving the proper dose. Other patients don't like the taste powder inhalers can leave in their mouths.
Divo explains his priority is making sure patients have an inhaler they are comfortable using and that they can afford. But, when appropriate, he'll keep offering the dry powder option.
Changing inhaler technology largely voluntary, not mandatory
Advocacy groups for asthma and COPD patients support more conversations about the connection between inhalers and climate change.
"The climate crisis makes these individuals have a higher risk of exacerbation and worsening disease," says Albert Rizzo, chief medical officer of the American Lung Association. "We don't want medications to contribute to that."
There are ongoing efforts to make metered-dose inhalers more climate-friendly, Rizzo says. The United States and many other countries are phasing down the use of hydrofluorocarbons, which are also used in refrigerators and air conditioners. It's part of the global attempt to avoid the worst possible impacts of climate change. But inhaler manufacturers are largely exempt from those requirements and can continue to use the gases while they explore new options.
Some leading inhaler manufacturers have pledged to produce canisters with less potent greenhouse gases and to submit them for regulatory review by next year. It's not clear when these inhalers might be available in pharmacies.
Separately, the FDA is spending about $6 million on a study about the challenges of developing inhalers with a smaller carbon footprint.
Will new kinds of inhalers come with painful price hikes?
Rizzo and other lung specialists worry these changes will translate into higher prices. That's what happened in the early to mid-2000s when ozone-depleting chlorofluorocarbons (CFCs) were phased out of inhalers. Manufacturers changed the gas in metered-dose inhalers and the cost to patients nearly doubled. Today, many of those re-engineered inhalers remain expensive.
Dr. William Feldman, a pulmonologist and health policy researcher at Brigham and Women's Hospital, explains that these dramatic price increases occur because manufacturers register updated inhalers as new products, even though they deliver medications already on the market.
The manufacturers are then awarded patents, which prevent the production of competing generic medications for decades. The Federal Trade Commission says it is cracking down on this practice.
After the CFC ban, "manufacturers earned billions of dollars from the inhalers" that were re-engineered, Feldman says.
When inhaler costs went up, physicians say, patients cut back on puffs and suffered more asthma attacks. Gregg Furie, medical director for climate and sustainability at Brigham and Women's Hospital, worries that's about to happen again.
"While these new propellants are potentially a real positive development, there's also a significant risk that we're going to see patients and payers face significant cost hikes," Furie says.
Some of the largest inhaler manufacturers, including GSK, are already under scrutiny for allegedly inflating prices in the United States. GSK spokeswoman Sydney Dodson-Nease told NPR and KFF Health News that the company has a strong record for keeping medicines accessible to patients, but that it's too early to comment on the price of the more environmentally sensitive inhalers the company is developing.
How pharmacists, insurers, and regulators could help
Developing affordable, effective, and climate-friendly inhalers will be important for hospitals as well as patients. The Agency for Healthcare Research and Quality recommends that hospitals looking to shrink their carbon footprint reduce inhaler emissions. Some hospital administrators see switching inhalers as low-hanging fruit on the list of climate-change improvements a hospital might make.
"Swapping inhalers" sounds easy to do, but the issues are more complex than that, according to Brian Chesebro, medical director of environmental stewardship at Providence, a hospital network in Oregon.
Even among metered-dose inhalers, the climate impact varies, Chesebro says. So pharmacists should play a role in suggesting the inhalers with the fewest greenhouse gas emissions. Insurers should also adjust reimbursements to favor climate-friendly alternatives, he says, and regulators could consider emissions when reviewing hospital performance.
Dr. Samantha Green, a family physician in Toronto, said clinicians can make a big difference with inhaler emissions by starting out with a basic question: Does the patient in front of me really need one?
Green, who works on a project to make inhalers more environmentally sustainable, explains that research shows a third of adults diagnosed with asthma may not have the disease.
"So that's an easy place to start," Green says. "Make sure the patient prescribed an inhaler is actually benefiting from it."
Green said educating patients has a measurable effect. In her experience, patients are moved to learn that emissions from the approximately 200 puffs in one inhaler are equivalent to driving about 100 miles in a gas-powered car. Some researchers say switching to dry powder inhalers may be as beneficial for the climate as a patient adopting a vegetarian diet.
One of the hospitals in Green's health care network, St. Joseph's Health Centre, found that talking to patients about inhalers led to a significant decrease in the use of metered-dose devices. Over six months, the hospital went from 70% of patients using the puffers, to 30%.
Patients who switched to dry powder inhalers have largely stuck with them, Green says, and appreciate using a device that is less likely to exacerbate the environmental conditions that inflame asthma.
This article comes from NPR's health reporting partnership with WBUR and KFF Health News.
