New data show overuse of reliever medication in asthma is responsible for 250,000 tonnes of greenhouse gas emissions every year in the UK

Analysis of UK inhaler medicine use and carbon footprint presented at the British Thoracic Society Winter Meeting

New analysis of respiratory inhaler medicine use in the UK shows that 83% of all short-acting beta2-agonist (SABA) relievers for asthma are prescribed to patients who are potentially overusing their reliever medication.1 The overuse of SABA relievers is responsible for 250,000 tonnes of CO2 equivalent annually.1

These findings will be presented at the British Thoracic Society Winter Meeting and are based on SABA prescription and use data extracted from the UK study in the SABA Use IN Asthma (SABINA) global programme of harmonised, large-scale observational studies collected between 2007-2017.2

The prescription of three or more SABA inhalers per year is associated with poor asthma control, approximately twice the number of exacerbations compared with low SABA users (prescribed 0-2 inhalers/year) and increased asthma-related healthcare utilisation.2,3 Asthma is a chronic, variable, inflammatory disease affecting 5.4 million people in the UK (4.3 million adults) and can cause asthma attacks and symptoms including breathlessness and wheezing.4,5 Every 10 seconds someone in the UK has a potentially life-threatening asthma attack with, on average, three people dying from asthma every day.5

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: “Overuse of reliever inhalers in asthma is widespread in the UK and associated with an increased risk of exacerbations for patients, highlighting the importance of adopting strategies to improve disease control and reduce short-acting beta2-agonist overuse. This new analysis shows that reliever overuse is also a major contributor to greenhouse gas emissions in respiratory care, similar to driving an average diesel car for about 900 million miles. These findings are important for informing clinical guidelines and healthcare policies to support improvements in asthma care while also realising carbon savings.”

Alex de Giorgio-Miller, Vice President, Medical & Scientific Affairs, AstraZeneca UK, said: “We know that the overuse of SABA reliever inhalers is associated with an increased risk of severe asthma attacks, but this analysis highlights the scale of the problem we face in the UK, both in terms of poor health outcomes and the corresponding greenhouse gas burden. By reducing over-reliance on SABA inhalers and improving asthma outcomes, we can also have an important positive impact on the environment.”

Further results from the analysis showed that SABA inhaler use drives 70% of greenhouse gas emissions (GHG) from inhaler devices in the UK.1 The per capita use of all SABA reliever inhalers in the UK was approximately treble or more than that observed in other large European countries, resulting in even higher GHG emissions.1

Asthma is a common chronic respiratory disease, and it affects the health and day-to-day lives of as many as 339 million adults and children worldwide.6 It is characterised by recurrent breathlessness and wheezing which varies over time, and in severity and frequency from person to person.7

All asthma patients are at risk of severe exacerbations regardless of their disease severity, adherence to treatment or level of control.8,9,10 There are an estimated 176 million asthma exacerbations globally per year;11 these are physically threatening and emotionally significant for many patients.12 However, despite asthma being a chronic, variable inflammatory disease, many patients are either under-prescribed or under-use their anti-inflammatory maintenance therapy and may over-rely on their SABA reliever, which can mask symptom worsening.13-16 Taking a SABA inhaler alone during a worsening of symptoms does not address the underlying inflammation, leaving patients at risk of asthma exacerbations and potential exposure to frequent bursts of oral corticosteroids.17

The Global Initiative for Asthma no longer recommends SABA taken as-needed as the preferred reliever therapy.4 Prescription of three or more SABA inhalers per year is associated with increased risk of poor clinical outcomes in asthma as well as hospitalisation.4

Ambition Zero Carbon
The most common reliever inhalers in asthma care include hydrofluoroalkane (HFA) propellants responsible for GHG emissions, which have a high climate impact.18 AstraZeneca has committed to converting its respiratory inhalers containing HFA propellants to near-zero Global Warming Potential (GWP) propellants. The conversion to near-zero inhalers is part of AstraZeneca’s wider Ambition Zero Carbon programme, which aims to achieve zero carbon emissions from operations across the world by 2025 and to ensure our entire value chain is carbon negative by 2030, bringing forward decarbonisation plans by more than a decade.

Overuse of SABA in the UK is responsible for 250,000 tonnes of CO2 equivalent annually, which has a carbon footprint similar to driving an average diesel car for approximately 900 million miles.1,19

The SABA Use IN Asthma (SABINA) global 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 across 40 countries.20

SABINA includes over 1.5 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 24 countries across 5 continents.
  • SABINA+ – Multi-design extended pillar for countries that joined after initiation of the programme (China, Morocco, Poland, Romania, Switzerland, and the US).

Results from the SABINA programme published to date have shown that prescription or collection of three or more SABA inhalers per year is associated with poor asthma control, approximately twice the number of exacerbations compared with low SABA users (prescribed 0-2 inhalers/year) and increased asthma-related healthcare utilisation.2,3

In SABINA I, an analysis of the prescriptions for SABA inhalers for patients with asthma showed that 83% of those were for patients who were prescribed three or more SABA inhalers per year.1

AstraZeneca in Respiratory & Immunology
Respiratory & Immunology is one of AstraZeneca’s three therapy areas and is a key growth driver for the Company.

Building on a 50-year heritage, AstraZeneca is an established leader in respiratory care across inhaled and biologic medicines. AstraZeneca aims to transform the treatment of asthma and chronic obstructive pulmonary disease (COPD) by eliminating preventable asthma attacks across all severities and removing COPD as leading cause of death through earlier, biology-led treatment. 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 immune-driven diseases. The Company’s growing presence in immunology is focused on five mid- to late-stage franchises with multi-disease potential in rheumatology (including systemic lupus erythematosus), dermatology, gastroenterology and systemic eosinophilic-driven diseases. AstraZeneca’s ambition in immunology is to achieve disease control and ultimately clinical remission in targeted immune-driven diseases.

AstraZeneca (LSE/STO/Nasdaq: AZN) is a global, science-led biopharmaceutical company that focuses on the discovery, development and commercialisation of prescription medicines, primarily for the treatment of diseases in three therapy areas - Oncology, 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. Please visit and follow the Company on Twitter @AstraZeneca.

For details on how to contact the Investor Relations Team, please click here. For Media contacts, click here.


1. Wilkinson AJK, Menzies-Gow A, Sawyer M, 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.

2. Bloom CI, Cabrera C, Arnetorp S, et al. Asthma-Related Health Outcomes Associated with Short-Acting β2-Agonist Inhaler Use: An Observational UK Study as Part of the SABINA Global Program. Adv Ther 2020; 37: 4190–4208.

3. Nwaru BI, Ekström M, Hasvold P, et al. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020; 55 (4): 1901872.

4. Global Initiative for Asthma. 2020 GINA Report, Global Strategy for Asthma Management and Prevention. [Online]. Available at: [Last accessed: 1 Feb 2021]

5. Asthma facts and statistics. [Online] Available at: [Last accessed: 1 Feb 2021]

6. The Global Asthma Network. The Global Asthma Report 2018. [Online]. Available at: [Last accessed: 1 Feb 2021].

7. National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3). [Online]. Available at: [Last accessed: 1 Feb 2021].

8. Olaguibel JM, Quirce S, Julia B, et al. Measurement of asthma control according to Global Initiative for Asthma guidelines: a comparison with the Asthma Control Questionnaire. Respir Res. 201; 13: 50. 

9. Price D, Fletcher M, van der Molen T. Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey. NPJ Prim Care Respir Med. 2014; 24: 14009. 

10. Bateman ED, Hurd SS, Barnes PJ, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J. 2008; 31: 143–78.

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

12. Sastre J, Fabbri LM, Price D, 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.

13. Humbert M, Andersson TL, Buhl R. Budesonide/formoterol for maintenance and reliever therapy in the management of moderate to severe asthma. Allergy. 2008; 63: 1567–80. 

14. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the asthma insights and reality in Europe (AIRE) study. Eur Respir J. 2000; 16: 802–7. 

15. Tattersfield AE, Postma DS, Barnes PJ, et al. on behalf of the FACET International Study Group. Exacerbations of asthma: a descriptive study of 425 severe exacerbations. Am J Respir Crit Care Med. 1999; 160: 594–9. 

16. Adams RJ, Fuhlbrigge A, Guilbert T, et al. Inadequate use of asthma medication in the United States: results of the asthma in America national population survey. J Allergy Clin Immunol. 2002; 110: 58–64. 

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

18. Panigone S, Sandri F, Ferri R, et al. Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment. BMJ Open Respir Res. 2020; 7 (1): e000571.

19. Guidance on how to measure and report your greenhouse gas emissions. [Online] Available from [Last accessed: 1 Feb 2021].

20. Cabrera CS, Nan C, Lindarck N, 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: Z4-30765
Date of Preparation: February 2021