How patients were involved in the creation of this article

A patient with asthma is a co-author on this article. They agreed the outline on the article, and suggested a greater emphasis on practical steps, and the importance of shared decision making. They reviewed the initial draft and made multiple changes to structure and content, in particular suggesting emphasising the value of specialist nurses and pharmacists, as well as changes to language around patient empowerment. They reviewed all suggested resources to ensure they were appropriate and valuable from a patient perspective.

In addition, as a result of an external patient review, arranged by the BMJ we made it clearer that there are multiple ways to reduce environmental impact, including options for different global settings. We also explicitly stated that patients should not stop their inhalers and emphasised that poorly controlled asthma carries the greatest environment burden. We highlighted more strongly that it is the responsibility of the system not the individual to reduce the environmental impact of care.

How this article was created

To write this clinical update we started with the personal archives of references on asthma care and environmental impact of James Smith and LJ Smith. We supplemented this with a Medline search using terms (environmental OR carbon OR net zero) AND inhaler. NICE, BTS, SIGN, and GINA guidelines were searched for reference to environmental impact. The Cochrane Database was searched for reference to inhalers. International guidelines were sought by searching respiratory society websites.

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