CARBON studies showed uncontrolled asthma is associated with an increased carbon footprint of asthma care

Excess greenhouse gas emissions due to uncontrolled asthma were eight times higher than controlled asthma which equates to approximately 300,000 tonnes of avoidable CO2 emissions in the UK per year

Over-reliance on SABA relievers contributed to avoidable per capita emissions in Europe and Canada

Results from two new observational analyses of the healthCARe-Based carbON cost of treatment (CARBON)1 global programme of respiratory studies showed uncontrolled asthma, which is associated with increased healthcare resource utilisation (HCRU) including exacerbations, GP consultations, hospital outpatient visits and over-reliance of short-acting beta2-agonist (SABA) relievers, accounted for a substantial proportion of the carbon footprint associated with asthma care. The findings were presented at the European Respiratory Society (ERS) International Congress 2021.

Data from the SABINA CARBON UK2 study demonstrated that patients 12 years and older whose asthma was uncontrolled (n=111,844) were associated with a higher carbon footprint than those with well controlled asthma (n=124,662). This is the first real-world evidence study to quantify greenhouse gas (GHG) emissions attributable to front line asthma care, comparing controlled and uncontrolled asthma based on the carbon footprint of prescriptions and HCRU.

Excess GHG emissions per capita were eight times higher for patients with uncontrolled asthma (one or more exacerbations in the past 12 months or prescribed three or more SABA inhalers/year),2,3 compared with patients with controlled asthma (no exacerbations and prescribed 0-2 SABA inhalers/year). The excess GHG emissions associated with uncontrolled asthma were due to GP and hospital care resulting from asthma attacks plus over-reliance on SABA relievers (three or more inhalers/year).2,3

The findings showed GHG emissions associated with asthma-related care were approximately 750,000 tonnes of CO2 equivalent per year, of which excess GHG emissions associated with uncontrolled asthma were approximately 300,000 tonnes of CO2 equivalent (based on scaling to the UK asthma population of 5.4 million).4

In the SABA CARBON Europe and Canada5 study, which assessed asthma inhaler prescription and dispensing data in patients 12 years and older from five European countries and two Canadian provinces, the results showed that 69-94% of total SABAs were received by patients who were over-reliant on their reliever (three or more inhalers/year)3. SABA over-reliance is an indicator of poor asthma control,6,7 risk of asthma exacerbations,8 and also contributes to excess GHG emissions.2

Alexander J. K. Wilkinson, Consultant in Respiratory and General Medicine, East and North Hertfordshire NHS Trust, Stevenage, UK and lead author of the study said: “Results from the CARBON studies suggest that reducing exacerbation risk and improving asthma control go hand in hand with reducing greenhouse gas emissions. Optimising care by implementing guidelines that reduce both exacerbations and SABA overuse could also have the benefit of reducing the carbon footprint of asthma care.”

Mene Pangalos, Executive Vice-President, BioPharmaceuticals R&D said: “These data are incredibly important as they demonstrate the impact of uncontrolled asthma on increased greenhouse gas emissions. More than 176 million asthma attacks occur globally each year, so it’s critical to improve outcomes for people living with asthma, not only to reduce their risk of potentially life-threatening attacks, but also to lessen the environmental consequences of poor asthma control. At AstraZeneca, we are focused on developing and delivering healthcare that supports healthy people and a healthy planet, and are committed to working with our sector to accelerate the transition to net zero.”

CARBON is the first programme to calculate the impact of poor disease control or disease progression on the carbon footprint of respiratory care and comprises more than 2 million patients globally.1

AstraZeneca will present data from four studies from the CARBON programme at ERS. These data add to the growing body of evidence demonstrating the carbon footprint of uncontrolled respiratory disease. Earlier this year at the British Thoracic Society Winter Meeting, AstraZeneca presented an analysis of UK inhaler medicine which showed that SABA use was a major contributor to GHG emissions in respiratory treatment.9  

Asthma is a chronic, inflammatory, fluctuating disease that leaves patients at risk of exacerbations.10 The disease affects the health and day-to-day lives of as many as 339 million adults and children worldwide.10 Patients experience recurrent breathlessness and wheezing, which varies over time, and in severity and frequency.10

Patients with asthma are at risk of severe exacerbations regardless of their disease severity or level of control.11,12 There are an estimated 176 million asthma exacerbations globally per year;13 these are physically threatening and emotionally significant for many patients14 and can be fatal.10 Inflammation is central to both asthma symptoms10 and exacerbations.15 Many patients experiencing asthma symptoms use a SABA as a reliever medication, however taking a SABA alone does not address inflammation, leaving patients at risk of exacerbations and requiring frequent bursts of oral corticosteroids.8,16,17 International recommendations from the Global Initiative for Asthma no longer recommends SABA as the preferred reliever therapy across all asthma severities.3

Ambition Zero Carbon
AstraZeneca’s Ambition Zero Carbon strategy was launched in January 2020. With an investment of approximately $1 billion, the Company is committed to becoming zero carbon across its global operations by 2025 and carbon negative across its entire value chain by 2030. AstraZeneca is committed to disease prevention, early detection, early diagnosis and optimal treatment of disease - to keep our populations healthy while reducing environmental impact. AstraZeneca is working in partnership with governments, businesses, academia, civil society and many more actors to accelerate the transition to a more sustainable net-zero future.

The most common reliever inhalers in asthma care include hydrofluoroalkane (HFA) propellants responsible for GHG emissions, which have a high climate impact. As part of AstraZeneca’s wider Ambition Zero Carbon programme, the Company has committed to developing the next generation of pressurised metered dose inhalers containing a near-zero Global Warming Potential propellant.

The healthCARe-Based carbON cost of treatment (CARBON)1 programme aims to calculate the impact of poor disease control and disease progression on the carbon footprint of respiratory care. The programme aims to highlight how guideline implementation and better management can drive improvements in patient care and reduce the carbon footprint of respiratory care. CARBON is currently comprised of seven studies including approximately 2.5 million patients with data collected between 2007-2022 in 40 countries.

SABINA CARBON UK2 was a longitudinal, observational, study that aimed to quantify the GHG emissions associated with asthma care in the UK. The focus was the carbon footprint of controlled versus uncontrolled asthma. Asthma control status was assigned during a baseline year and then the GHG emissions associated with asthma-related prescribing and HCRU were quantified during 12 months of follow up. In the baseline period, well controlled asthma was defined as the prescription of fewer than three SABA inhalers per year and no exacerbations, while asthma that was uncontrolled was defined as prescription of three or more SABA inhalers/year and/or one or more asthma exacerbations. The study included patients 12 years and older with current asthma in a 12-month follow-up period between 2008 and 2019 in the UK. Overall, excess GHG emissions associated with uncontrolled asthma were 303,221.5 tonnes of CO2 equivalent while excess GHG emissions associated with asthma that was well controlled were 30,410.7 tonnes of CO2 equivalent. Excess GHG emissions were those emissions associated with healthcare and prescribing resulting from asthma exacerbations (attacks) or the over-reliance on SABA reliever inhalers.

SABA CARBON Europe-Canada
The SABA CARBON Europe-Canada6 study evaluated the volume and carbon footprint of SABA use (vs total inhaler use) in all respiratory conditions, and GHG emissions associated with potential SABA overuse in asthma between 2006-2019 in Sweden, Italy, Poland Germany, U.K. and the Canadian provinces of Nova Scotia and Alberta.

The SABA Use IN Asthma (SABINA)18 programme, funded by AstraZeneca, is the largest real-world data analysis of clinical outcomes related to SABA use and maintenance therapy in asthma, consisting of an innovative framework of harmonised, large-scale observational studies collected between 2006-2019 in 40 countries. The studies evaluated diverse asthma populations, healthcare systems and asthma management strategies.6,8,18

SABINA includes over 1 million asthma patients globally and has four main pillars:

  • SABINA I – Retrospective observational database study in the UK
  • SABINA II – Retrospective observational database study in 8 countries (France, Germany, Italy, Netherlands, Spain, Sweden, Canada and Israel)
  • SABINA III – Cross-sectional study conducted in 25 countries across 5 continents
  • SABINA+ – Multiple designs extended pillar for countries that joined after initiation of the programme (China, Morocco, Poland, Romania, Switzerland, and the US)

AstraZeneca in Respiratory & Immunology
Respiratory & Immunology, part of BioPharmaceuticals, is one of AstraZeneca’s main disease areas and is a key growth driver for the Company. 

AstraZeneca is an established leader in respiratory care with a 50-year heritage. The Company aims to transform the treatment of asthma and COPD by focusing on earlier biology-led treatment, eliminating preventable asthma attacks, and removing COPD as a top-three leading cause of death. The Company’s early respiratory research is focused on emerging science involving immune mechanisms, lung damage and abnormal cell-repair processes in disease and neuronal dysfunction. 

With common pathways and underlying disease drivers across respiratory and immunology, AstraZeneca is following the science from chronic lung diseases to immunology-driven disease areas. The Company’s growing presence in immunology is focused on five mid- to late-stage franchises with multi-disease potential, in areas including rheumatology (including systemic lupus erythematosus), dermatology, gastroenterology, and systemic eosinophilic-driven diseases. AstraZeneca’s ambition in Respiratory & Immunology is to achieve disease modification and durable remission for millions of patients worldwide. 

AstraZeneca (LSE/STO/Nasdaq: AZN) is a global, science-led biopharmaceutical company that focuses on the discovery, development, and commercialisation of prescription medicines in Oncology, Rare Diseases, and BioPharmaceuticals, including Cardiovascular, Renal & Metabolism, and Respiratory & Immunology. Based in Cambridge, UK, AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide.

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1. Wilkinson A, et al. Is respiratory care carbon conscious? Rationale and future implications for the CARBON respiratory programme. Poster presented at 10th International Primary Care Respiratory Group (IPCRG) World Conference, 2021 May 6–8; Dublin, Ireland.  

2. Wilkinson A. et al. Greenhouse gas emissions associated with asthma care in the UK: results from SABINA CARBON. Oral session presented at European Respiratory Society (ERS) International Congress, 2021 Sep 5-8.

3. Global Initiative for Asthma. 2021 GINA Report, Global Strategy for Asthma Management and Prevention. [Online]. Available at:  [Last accessed: September 2021]. 

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9. Wilkinson AJK, et al. An assessment of short-acting β2-agonist (SABA) use and subsequent greenhouse gas (GHG) emissions in five European countries and the consequence of their potential overuse for asthma in the U.K. BTS Oral Abstract No: S26.

10. The Global Asthma Network. The Global Asthma Report 2018. [Online]. Available at: [Last accessed: September 2021].

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12. Bloom CI, Nissen F, Douglas IJ, Smeeth L, Cullinan P, Quint JK. Exacerbation risk and characterisation of the UK’s asthma population from infants to old age. Thorax. 2018 Apr 1;73(4):313-20.

13. AstraZeneca Pharmaceuticals. Data on File. Budesonide/formoterol Data on File: Annual Rate of Asthma Exacerbations Globally. (ID: SD-3010-ALL-0017).

14. Sastre J, et al. Insights, attitudes, and perceptions about asthma and its treatment: a multinational survey of patients from Europe and Canada. World Allergy Organ J. 2016; 9: 13.

15. Wark PA, et al. Asthma exacerbations· 3: pathogenesis. Thorax. 2006 Oct 1;61(10):909-15.

16. Kaplan A, et al. Effective asthma management: is it time to let the AIR out of SABA?. Journal of clinical medicine. 2020 Apr;9(4):921.

17. Price DB, et al. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy. 2018; 11: 193–204.

18. Cabrera CS, et al. SABINA: global programme to evaluate prescriptions and clinical outcomes related to short-acting β2-agonist use in asthma. Eur Respir J. 2020; 55 (2):1901858.

Veeva ID: Z4-36459
Date of Preparation: September 2021