Winds of Change – One Puffer at a Time

by Dr Monica Theron

MBChB, ClinDipPallMed, FRACGP and FASLM

Short wind, the topic of our Shared Medical Appointment in Mparntwe/Alice Springs.

We talk about short wind causes. Heart troubles. Sick kidneys and missing dialysis. Spirit no good – getting upset or sad. And, short wind from the lungs. But the lungs? Often last on the list at a GP consult.

We prescribe pressured metered-dose inhalers (pMDIs) out of habit. They are familiar and effective. Widely used and may need a spacer. However, their environmental impact is significant and hidden.

The carbon footprint of me driving my petrol car from the Central Australia to Naarm/Melbourne is equivalent to around 8 to 13 pMDIs^[1]. We, as clinicians can prescribe with the same clinical confidence, but far less environmental cost. Dry powder inhalers (DPI’s) and soft mist inhalers (SMI’s) are equally effective for most adult and adolescent patients. Preferred by many due to easier technique and up to 90% lower in emissions. Inhaler prescribing has come a long way. The strange era of asthma cigarettes with stramonium and belladonna was common practice early in the previous century. A turning point in the 1950s was when an 11 year old girl named Susie Maison asked: “Daddy, why can’t they put my asthma medicine in a spray-can like they do hair spray?” This sparked the invention of the pMDI which did transform respiratory care. DPI’s only gained real traction from the 1990s^[2].

According to Asthma Australia’s National Sustainable Asthma Care Roadmap, 25 million inhalers are sold per year in Australia. Eighty three percent of those are pMDI’s which equates to 600 000 tonnes of CO emissions. This is equivalent to operating 350 000 petrol cars or 45 000 households. The main culprit is the hydrofluorocarbon propellant in pMDI’s. Dry powder inhalers do not contain this propellant as it is breath activated^[3]. In Australia, up to 90% of people are not using their inhalers correctly. The greenest puffer is the one the patient will use and use correctly^[4]. How can we as 21st century clinicians and the broader public assist with the short-wind of our patients and of the environment?

The new Asthma handbook 2025 guidelines recommend anti-inflammatory relievers (AIR) or maintenance and reliever therapy (MART) with inhaled corticosteroids (ICS), moving away from “blue puffer” only treatment for adolescents and adults. This aligns with global best practice to improve control, reduce oral steroids reliance and fewer severe attacks^[5]. Acknowledging New-Zealand’s approach as DPI’s preferred first line treatment for adult and adolescent asthma^[6].

We have the power to reduce carbon emissions from inhalers by up to 90%. A petrol car from Naarm/Melbourne to Central Australia emits the equivalent of 452 dry powder or soft mist inhalers. Not a mere 8 – 13 pressured MDIs.

The greenhouse gas propellants from pMDI’s can continue to leak into the atmosphere if not discarded appropriately. Empty and unwanted inhalers can be taken to pharmacies for safe disposal free of charge. The puffer’s plastic case may be suitable for the household recycling bin^[7].

This is not about doing more; it’s about prescribing with intention. A strength-based approach that values clinical care and planetary health. Another tool in the toolkit to augment the unofficial 7th Lifestyle Medicine pillar Nature.

Let’s change the winds together, one puffer at a time.

The Project

A clinical audit in Northern Territory’s largest Aboriginal Community Controlled Health Organisation consisting of town and remote clinics to encourage prescribers to consider prescribing environmentally friendly inhalers in adults.

Objectives

Implement the intervention in routine practice
Compare inhaler prescribing rates pre- and post-intervention
Gather prescriber feedback
Explore patient-related factors

Simple tools and clinical prompts that make sustainable prescribing easier.

I am hopeful that this wind of insight translates into action – guiding sustainable inhaler prescribing across Central Australia, from town clinics to remote communities

We welcome collaboration on this project; feel free to reach out to Monica on monica.theron@caac.org.au.

References

National Institute for Health and Care Excellence (NICE). “Asthma: diagnosis, monitoring and chronic asthma management (NG245).” 2024. https://www.nice.org.uk/guidance/ng245 (accessed 7 Dec 2025)
Stein SW, Thiel CG. “The History of Therapeutic Aerosols: A Chronological Review.” J Aerosol Med Pulm Drug Deliv.2017;30(1):20-41. doi:10.1089/jamp.2016.1297.
Asthma Australia. “The National Sustainable Asthma Care Roadmap – Roundtable Report.” 2024. https://asthma.org.au/about-us/advocacy/the-national-sustainable-asthma-care-roadmap/ (accessed 7 Dec 2025)
D Rigby. “Inhaler device selection for people with asthma or chronic obstructive pulmonary disease.” Aust Prescr.2024;47:140-147. doi:10.18773/austprescr.2024.046.
Asthma Australia. “Asthma Digest – AAH Update 2025.” 2025. https://asthma.org.au/health-professionals/asthma-digest/aah-update-2025/ (accessed 7 Dec 2025)
Asthma Foundation New Zealand. “The environmental impact of inhalers.” 2025. https://www.asthmafoundation.org.nz/stories/the-environmental-impact-of-inhalers (accessed 7 Dec 2025)
National Asthma Council Australia. “Puffer and inhaler care – Factsheet.” 2025. https://files.nationalasthma.org.au/resources/Puffer-and-inhaler-care_-Factsheet.pdf (accessed 7 Dec 2025)

Dr Monica Theron

Monica is a General Practitioner with special interests in Indigenous health, lifestyle medicine and palliative care. She is a Fellow of the Australasian Society of Lifestyle Medicine and a Fellow of Royal Australian College of General Practitioners. Alice Springs NT has been home for the past eight years, providing unique opportunities to work with diverse health organisations including Central Australian Aboriginal Congress and Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation (Purple House) in Mparntwe/Alice Springs, NT.

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