Patient Attitudes, Beliefs, and Practices in Environmentally Friendly Inhaler Disposal: A Mixed-Methods Evaluation with Behaviourally Informed Recommendations

Patient Attitudes, Beliefs, and Practices in Environmentally Friendly Inhaler Disposal: A Mixed-Methods Evaluation with Behaviourally Informed Recommendations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Patient Attitudes, Beliefs, and Practices in Environmentally Friendly Inhaler Disposal: A Mixed-Methods Evaluation with Behaviourally Informed Recommendations Delyth James, Terence J. McElvaney, Thomas Henstock, Hannah Thomas, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7179716/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract The National Health Service (NHS) aims to reduce emissions from inhalers, a major contributor to its carbon footprint. Despite willingness, patient awareness and engagement with appropriate inhaler disposal and recycling remains low. This paper combines two studies both using behavioural frameworks with different methodological approaches to explore inhaler disposal behaviours, and barriers and facilitators to recycling uptake. Synthesis of two datasets from quantitative (Study 1) and qualitative (Study 2) studies was undertaken, and deductive analysis was conducted, based on the COM-B (Capability, Opportunity, Motivation) model of behaviour. Findings were mapped to the Behaviour Change Wheel (BCW) to provide recommendations for improving disposal practices. Inhaler users were unaware of the need to return inhalers to pharmacies for disposal and often discarded them in domestic waste. Inhaler users viewed community pharmacies as convenient locations for recycling schemes due to their proximity to the local pharmacy. However, they were unlikely to engage with initiatives that require significant additional effort such as traveling out of their way to return to the inhaler. Although awareness of environmental impacts can motivate intentions to recycle, users often struggle to develop and maintain consistent recycling habits. This highlights the complexity of behaviour change, requiring interventions that address psychological, physical, and social barriers. By applying behaviour change frameworks such as COM-B and the BCW, targeted strategies can be designed to enhance inhaler recycling. These include national educational campaigns to raise awareness, better signposting and prompts in healthcare settings, providing feedback on environmental benefits, persuasive messaging linking disposal to carbon reduction, and incentivization to encourage participation. A whole-system approach, engaging all healthcare professionals, is critical for sustained behaviour change and broader reach. Future research should focus on implementing and evaluating these interventions to identify the most effective methods for improving inhaler disposal/recycling and reducing the environmental impact of inhaler use. Earth and environmental sciences/Environmental sciences Health sciences/Health care Figures Figure 1 Figure 2 Figure 3 INTRODUCTION By 2026, the National Health Service (NHS) is expected to deliver a 50% reduction in carbon emissions produced from waste management (NHS England, 2023 ) rising to 80% by 2028–2032 (NHS England, 2023 ; NHS Wales, 2021 ). Metered dose inhalers (MDIs) are one of the greatest single contributors to carbon emissions across the NHS (Wilkinson et al, 2019 ; Erskine, 2022 ) since they contain hydrofluorocarbon (HFCs) propellants, estimated to account for 4% of all NHS carbon dioxide (CO 2) emissions. One estimate is that 73 million inhalers are dispensed every year (The Pharmaceutical Journal, 2019 ). There is a lack of data regarding the current disposal behaviours of inhaler users. Various initiatives have been proposed to reduce the significant global warming impact from inappropriate MDI disposal (Murphy et al, 2023a ) involving prescribing less inhalers (Caron et al, 2024 ; ), switching to a non-HFC inhaler (Janson et al, 2023 ; Wilkinson et al, 2019 ) or the implementation of recycling schemes (Murphy et al, 2023a ; Seage et al, 2025 ). Inhaler recycling involves collection and disposal of MDIs by a specialist waste contractor where the plastic, metal and gas are recovered and reused. This inhaler recycling technology has already been successfully used in a small number of trials run by NHS Trusts across England and Wales and in projects run by two major pharmaceutical companies (The Pharmaceutical Journal, 2025 ). One example is a project that took place in community pharmacies and hospitals across Leicestershire, England, estimated to have saved the equivalent of 305.3 tonnes of CO 2 emissions from entering the atmosphere where 52,148 inhalers were received via postal return over a 24-month period (Murphy et al, 2023a ). To our knowledge there are currently no centralised national schemes in place in the UK utilising this or alternative approaches to dispose of these inhalers in an environmentally friendly way. Patients are encouraged to return all unused and empty inhaler canisters (along with all other unwanted medicines) to the community pharmacy for safe disposal. Currently, these are incinerated along with all returned medicinal waste; however, the temperatures are not high enough to prevent carbon emissions from the MDIs, even if the canisters are empty, therefore still contributing to carbon emissions. The future implementation of a community pharmacy inhaler recycling scheme relies on engaging with patients to encourage environmentally friendly inhaler disposal. Several studies highlight limited public awareness regarding the environmental impact of inhalers. Hodge et al. ( 2024 ) found that 71% of inhaler users ( n = 61) were unaware that inhalers contain greenhouse gases. Similarly, over 80% of patients recruited from UK hospitals and GP practices were unaware that inhalers could be recycled (Sivarajasingam, 2021 ). While a high proportion of users (93%) expressed a desire for more environmental information about MDIs (Herrera et al., 2024 ), fewer than 15% of healthcare professionals routinely discussed inhaler recycling with their patients (Walpole et al., 2020). Other studies have shown that despite low initial awareness, many patients are open to more sustainable practices, expressing a willingness to recycle if accessible facilities are made available (Baithun et al., 2022 ). Murphy et al’s ( 2023a ) pilot postal return scheme showed high patient satisfaction, but initial uptake was slow, gradually increasing over time. Broader engagement with recycling initiatives remains limited. In a secondary care clinic, only 35% of patients ( n = 261) recycled their inhalers over six months, while 57% continued to dispose of them in the household waste (De Vos et al., 2020 ). In paediatric and community settings, educational efforts improved awareness of the need to recycle inhalers, however, consistent engagement with recycling schemes remained a challenge (Nurse et al., 2022 ). International studies echo these trends, with improper disposal practices remaining prevalent despite media advertisements or financial incentives being used to influence behaviour (Ong et al., 2020 ; Wajid, 2020). Further to this, Murphy et al ( 2024 ) reported that over half of patients ( n = 16/29; 55%) using an inhaler without a dose counter did not have the confidence to determine when their inhaler was empty; resulting in inhalers being returned either under or over-used. Across the existing literature, there is consensus that patient and staff education, availability of recycling points, and clearer communication from healthcare providers and pharmaceutical companies are essential. Incorporating recycling advice during consultations and leveraging general practice settings can significantly improve inhaler disposal practices, helping reduce environmental impact and supporting NHS sustainability goals. However, before effective solutions can be proposed, we need to understand the current behaviours, beliefs and attitudes of inhaler users towards environmentally friendly disposal. For this paper, the terms ‘appropriate inhaler recycling,’ ‘appropriate inhaler disposal’ and ‘environmentally friendly disposal’ refer to the behaviour of taking the used (or unused) inhaler back to the community pharmacy or engaging in an alternative inhaler recycling scheme such as the postal initiative described earlier. In this paper, we present a synthesis of the findings of two studies, conducted independently of each other, adopting two contrasting methodological approaches to assess the current rates of appropriate inhaler disposal and attitudes and beliefs about inhaler recycling, mapping our findings to the COM-B Model of behaviour. The first study was a quantitative evaluation of people’s awareness of the environmental impact of inhalers, their current inhaler disposal behaviours, and the factors impacting appropriate current and future inhaler disposal. The objectives were to: i) assess current rates of appropriate inhaler disposal (i.e. return to the pharmacy or engage with another recycling scheme), explore attitudes and beliefs about inhaler disposal; (ii) examine the awareness of the environmental impact of inhalers in general, and the environmental impact of inappropriate disposal (i.e. not returning to a pharmacy or following or engaging with a recycling scheme); and (iii) test the impact of different messaging on willingness to return inhalers to pharmacy. The second study was a qualitative evaluation of patients’ perspectives on returning used or unused inhalers to a community pharmacy. The aim of the study was to explore the perceived barriers and facilitators to appropriate inhaler disposal (i.e. returning to a pharmacy or engaging with another recycling scheme). Both studies were underpinned by a behavioural insights approach based on two inter-related psychological frameworks – the Behaviour Change Wheel (BCW) and the COM-B (Capability, Opportunity, Motivation) model of behaviour (Michie et al, 2011 ). The Behaviour Change Wheel The COM-B components lie at the core of the BCW, enabling outputs to be mapped to appropriate intervention functions. The BCW was developed to improve the design and implementation of behaviour change interventions (Michie et al, 2011 ) by providing a method of characterising interventions and linking them to target behaviours. The policy categories on the outer circle of the BCW are key to influencing change and are essential considerations for successful interventions (Fig. 1 ). The COM-B model allows the barriers to specific behaviours (i.e. environmentally friendly inhaler disposal) to be systematically explored (Fig. 2 ). The COM-B model is based on the concept that the interaction between several components, namely, the individual’s capability (C), opportunity (O) and motivation (M) can provide an explanation for why a particular behaviour (B) is or is not performed (Sinnott et al, 2015 ). For an intervention to be successful, one or more of these components need to be targeted for sustained behaviour change to occur. Aims and objectives The aim of this paper is to synthesise the findings from two independent studies to assess current inhaler users’ attitudes, beliefs, and practices related to inhaler disposal. To achieve this aim, the following objectives were set: To compare the findings from two studies to identify barriers and facilitators to appropriate inhaler disposal and synthesise the data by mapping to the COM-B model of behaviour. To map the synthesis of findings from both studies to the BCW to make behaviourally informed recommendations to support appropriate inhaler disposal behaviours. RESULTS Table 1 presents the relevant demographic and clinical characteristics of participants for both studies and their inhaler related practices. Table 1 Comparison of key participant characteristics for Studies 1 and 2 Study 1 (Quantitative) Study 2 (Qualitative) Number of participants n = 1,354 n = 11 Gender Male: 528 (39%) Female: 812 (60%) Other: 14 (1%) Male: 7 (64%) Female: 4 (36%) Age Range = 18–95 years Mean = 60.9 years (SD = 13.85) Range = 18–65 years No mean available Ethnicity White: 91% Black: 2.5% Asian: 2.5% Other: 4% White: 9 (82%) Black: 2 (18%) Asian: 0 (0%) Other: 0 (0%) Inhaler user / Guardian Inhaler user = 1,237 (91%) Guardian = 117 (9%) Inhaler user = 10 (91%) Guardian = 1 (9%) Diagnosis* Asthma: 1029 (76%) COPD: 298 (22%) Other: 122 (9%) Not ascertained Inhaler types* MDI = 1137 (84%) DPI = 433 (32%) SMI = 108 (8%) MDIs = 11 (100%) Currently return inhalers to pharmacy 284 (21%) 1 (9.1%) Awareness of : Carbon footprint changes (Study 1)** Existence of recycling schemes (Study 2) Need for recycling (Study 2) 199/1153 (17%) - - - 0 (0%) 0 (0%) *Some inhaler users had a diagnosis of both asthma and COPD or prescribed more than one type of inhaler which accounts totals over 100%. **Denominator lower due to attrition in survey respondent numbers. MDI = metered dose inhaler, DPI = dry powder inhaler; SMI = soft mist inhaler Study 1: Quantitative study – survey of inhaler disposal beliefs and practices Sample characteristics A sample comprising 1,354 participants took part in the survey, of which 91% ( n = 1237) were inhaler users and 9% ( n = 117) were guardians (parents or carers) of patients prescribed inhalers. Of these, 60% ( n = 812) were female, 39% ( n = 528) were male and 1% ( n = 14) identified as other. The mean age of participants was 60.9 years (SD = 13.85). Of the sample, 76% ( n = 1029) reported being diagnosed with asthma, 22% ( n = 298) with COPD (some reported a diagnosis of both) and 9% ( n = 122) were prescribed an inhaler for another long-term respiratory condition. Of inhaler types, 84% ( n = 1137) were prescribed an MDI, 32% ( n = 433) a DPI and 8% ( n = 108) an SMI. Awareness of environmental impact of inhalers Only 17% ( n = 230) of participants responded that they were aware of the carbon footprint associated with inappropriate inhaler disposal. When tasked with estimating the carbon footprint of an MDI relative to miles driven in a standard petrol car, participants significantly underestimated the carbon footprint, with a median response of 20 miles compared to the actual mileage equivalent of approximately 107 miles ( r = -0.44, p < 0.001). Participants also significantly overestimated the relative carbon footprint of DPIs, with a median estimate of 10 miles compared to the actual equivalent of approximately 2 miles ( r = 0.70, p < 0.001). Current disposal awareness and practices Of the sample, 79% ( n = 1070) failed to return their inhalers to their local pharmacy with 44% ( n = 596) reporting that they dispose of them in the general waste, and 29% ( n = 393) disposing them in their standard recycling bin. When asked how they thought the NHS recommends they dispose of their inhalers, 70% ( n = 948) of participants failed to correctly identify the pharmacy as the appropriate channel for disposal. Facilitators and barriers to appropriate current and future inhaler disposal When asked why they disposed of their inhalers in the way they currently did most 56% ( n = 758) indicated that they simply did it out of habit, with only 30% ( n = 406) thinking that they were using the correct method. Nearly three-quarters of participants (74%; n = 1002) indicated that they had never received any guidance on how to dispose of their inhalers properly. The desire to adopt pro-environmental behaviours was high, with 84% ( n = 1137) indicating that reducing their carbon footprint was either “Important” or “Very important” to them. When presented with messaging encouraging appropriate inhaler disposal, participants showed a high likelihood to return their inhalers to the pharmacy in future (Mean likelihood score = 6.24 out of 7, SE = 0.04). Participants who saw a behaviourally informed message, specifically designed for the study (Message B, Mean likelihood score = 6.31, SE = 0.05), were significantly ( U = 19588.50, p = 0.008) more likely to return their inhalers than those who saw messaging based on current NHS communications (Message A, mean = 6.17, SE = 0 .05) (Fig. 3 ). Those who indicated they were unlikely to return their inhalers to the pharmacy in the future (10.7%, n = 143/1333) were also asked for their primary reasons. The most frequently reported reason (38%; n = 54/143) was related to the additional effort needed to return inhalers to the pharmacy. Other reasons cited as key barriers to appropriate disposal were forgetfulness (22%; n = 31/143) and recognising that changing their existing disposal habits might be challenging (13%; n = 19/143). Predictors of inhaler disposal by returning to the pharmacy Several factors significantly predicted whether participants reported the maximum likelihood of returning their inhalers to the pharmacy in future (χ 2 (17) = 136.97, p < .001). Those who saw Message B were significantly more likely to return their inhalers to the pharmacy in the future ( OR = 1.61, 95% CI = [1.04, 2.50], p = 0.033). Participants who indicated that reducing their carbon footprint was “Very important” were more likely to return their inhalers to the pharmacy in the future ( OR = 6.75, 95% CI = [4.06, 11.77], p < 0.001). Those who currently returned their inhalers to the pharmacy were more likely to continue to return them in future ( OR = 28.07, 95% CI = [5.46, 516.84], p = 0.001). Study 2: Qualitative study A sample of eleven patients from three geographic areas of Wales were recruited to the study, seven (64%) males and four (36%) females aged between 18–65 years old, of which ten (91%) were inhaler users and one (9%) was a guardian for someone prescribed an inhaler. Most participants were white (82%) ethnicity, and two participants were black. The reason for prescribing an inhaler was not ascertained for this sample. All were prescribed an MDI. None of the participants were aware that inhalers should be returned to the pharmacy for safe disposal and none had experience of using an inhaler recycling scheme. Table 2 provides illustrative quotes for each theme relating to barriers for inhaler recycling in the pharmacy. Three themes were identified relating to barriers to safe disposal of inhaler medication by returning to a community pharmacy. These were: Theme 1 – ‘I'm not going out of my way’; Theme 2 – ‘No-one told us’, and Theme 3 – ‘Will it really make a difference?’. Similarly, three themes were identified from the participant transcripts relating to enablers for the safe disposal of inhaler medication (Table 3 ). These were: Theme 1 - ‘Recycling aligns with my values ’ ; Theme 2 –’ I already recycle, so it shouldn't be a problem ’ and Theme 3 - ‘ How hard can it be? ’. Table 3 provides illustrative quotes for each theme relating to inhaler recycling in the pharmacy. Synthesis of findings from Studies 1 and 2. Tables 4 to 6 present the mapping of the barriers and facilitators from studies 1 and 2 to the COM-B Model components, highlighting the commonalities across the data sets. Table 4 presents the findings relating to factors affecting participants’ capability of disposing of inhalers appropriately. Table 2 Barriers to returning inhalers for recycling in the pharmacy: Illustrative quotes from qualitative interviews ( n = 11) Theme 1 - ‘I'm not going out of my way Theme 2 - ‘No-one told us’ Theme 3 - ‘Will it really make a difference?’ “ Anything extra, people are less likely to do because you are likely to forget ” (P2) “I've been taking pumps for 40 years now, longer than I'd care to admit, but it has never been pointed out to me that I could take the empty inhaler back to the pharmacy. And I've been through four or five pharmacies …just mention to people as they're picking things up, you know…. you would argue it probably isn’t a huge thing to just say ‘you can drop these things back here, bring your old ones back and we’ll give you your new one’ or whatever.” (P1). “Personally, I don't think it'll have much of an individual impact, if I recycle them or not, but I think with others it definitely will” (P3). “You can't take the old one in when you pick up the new one. So, you'd have to make, you'd almost have to make a special trip” (P1). “I don’t think I've actually been told by a pharmacist that you can take anything back” (P1). “So, the problem is that something like an inhaler, it seems so small and. You know, you look at the amount of recycling that you put out on a weekly basis and the amount of bin bags that people put out. Recycling, what you know, an inhaler once a month... I know it's important, but you will struggle to persuade people that it's important” (P2) “So, when you're tidying up, you think, oh, just chucking it in the bin, chucking it in the recycling. So yeah, that's the problem.” ( P2). “I have asked and several others, you know, how do we dispose of inhalers? Have you got a scheme? And they sort of just look at me blank sort of well no just put them in the bin and that's it” (P2) - - “Before I saw your study, I had literally not thought about this…” (P7). - - “…in my pharmacy, personally, I don’t really see any posters or leaflets anywhere” (P1). - Table 3 Enablers to returning inhalers for recycling in the pharmacy: Illustrative quotes from qualitative interviews ( n = 11) Theme 1 – ‘Recycling aligns with my values’ Theme 2 - ’ I already recycle, so it shouldn't be a problem ’ Theme 3 - ‘ How hard can it be?’ I think it's definitely important to take them where they need to go and recycle them properly” (P1). “Yeah. cause we recycle everything else. We pride ourselves on the fact. And you know, we're a family of four. And every fortnight we take out half a bin bag” (P2). “ I have to pick mine up from the pharmacy anyway. So, you know, it really doesn't get much easier than that” (P1) “I would be using it regardless of whether I get a reward or not; obviously it’s a nice benefit, but”… (P3). “I like to make sure that I do recycle and stay up, stay up on sustainability” (P4) . “I wouldn't have thought so. I should imagine it would be simply in a matter of handing them over” (P5) - “I'm quite big on not using propellant as much as possible” (P5). “Once a month we go there, so simply take anything that isn't used and isn't going to be used. (P5). - “ I do generally try to dispose of all my waste correctly and recycle if possible. So shouldn't really be any different for the inhaler” (P3). - Table 4 Mapping of barriers and facilitators from studies 1 and 2 relating to the Capability component of the COM-B Model Capability Commonalities Barriers identified in Study 1 survey data Barriers identified in Study 2 interview data Facilitators identified in Study 1 survey data Facilitators identified in Study 2 Interview data Psychological Capability Knowledge and awareness of the need for appropriate inhaler disposal 70% of participants did not know that the NHS recommends returning their inhaler to the pharmacy. Participants were unaware that inhalers could/or should be recycled. Participants who knew how they are supposed to dispose of inhalers were over 16 times more likely to return them to the pharmacy Participants who were aware that the method of inhaler disposal impacted emissions were over twice as likely to return them to the pharmacy. None Physical Capability Physical effort and skill needed to dispose of inhalers appropriately For the 11% of patients who said they would not return their inhalers in the future, 38% highlighted the additional effort required as a barrier. Free-text responses highlighted that some patients were not capable of making necessary visits to the pharmacy independently. Participants perceived themselves to not have the skills needed to be able to recycle inhalers correctly at home. Additional effort needed to plan additional journeys to the pharmacy to return inhalers for recycling. Reliance on public transport to travel to get to the pharmacy. None Participants felt that they would have the necessary skills to return inhalers to the pharmacy. Capability Barriers Both studies identified psychological and physical capability as key barriers to appropriate inhaler disposal. A major issue was low awareness or complete lack of knowledge about the need to recycle inhalers, along with insufficient guidance on how to do so. In Study 2, further psychological capability barriers included lack of attention to pharmacy return schemes, forgetting to recycle, and difficulty forming new recycling habits. Physical capability barriers were also common. Participants in both studies cited the extra effort required to travel to a pharmacy as a deterrent, with some in Study 1 unable to make the trip independently. In Study 2, reliance on public transport was highlighted as an additional challenge. Participants also reported lacking the skills to correctly identify which parts of the inhaler could be recycled at home. Capability Facilitators Study 1 found that psychological capability significantly influenced inhaler disposal: participants who knew how to dispose of inhalers were over 16 times more likely to return them to the pharmacy, and those aware of the environmental impact were over twice as likely. Study 2 did not identify any psychological capability facilitators. For physical capability , Study 2 interviews suggested that knowing which parts of the inhaler to recycle and being able to travel to the pharmacy without extra effort would support appropriate disposal. No physical capability facilitators were identified in Study 1 survey data, highlighting contrasting facilitator reporting across studies. Table 5 presents the findings relating to factors affecting participants’ opportunity of disposing of inhalers appropriately. Table 5 Mapping of barriers and facilitators from studies 1 and 2 relating to the Opportunity component of the COM-B Model Opportunity Commonalities Barriers identified in Study 1 survey data Barriers identified in Study 2 interview data Facilitators identified in Study 1 survey data Facilitators identified in Study 2 interview data Physical Opportunity Use of the pharmacy setting for recycling inhalers Some free-text responses highlighted that the pharmacy is too far away or not open at convenient hours. Some pharmacies do not currently offer an inhaler disposal service. Participants who use small, independent pharmacies perceived that their local pharmacy would not have the time, space, or resources to run a recycling scheme. Older participants were more likely to return inhalers, likely reflecting that they had more regular visits to pharmacy and so. Free-text responses indicated that convenient disposal points would encourage them to recycle. Inhaler users regularly visit the pharmacy and did not see handing inhalers back for recycling as onerous. Social Opportunity Healthcare professionals as a source of advice 74% said they’d never received any guidance, with 6% not recalling if they were given any guidance Participants stated that healthcare professionals had not informed them about how to dispose of inhalers Public messaging around this topic could shift social norms and expectations around proper disposal. Pharmacists viewed as an appropriate professional role to encourage engagement with inhaler recycling, Opportunity Barriers Physical opportunity was a significant barrier in both studies. Study 1 participants cited issues such as pharmacies being too far away, having limited opening hours, or not offering disposal services. In Study 2, those using small, independent pharmacies felt their local providers lacked the time, space, or resources to support inhaler recycling, with limited capacity emerging as a key theme. Social opportunity barriers were also evident. Across both studies, a major issue was the absence of advice from healthcare professionals on proper inhaler disposal. Over 80% of survey respondents in Study 1 reported not receiving or recalling any guidance, and participants in Study 2 consistently stated that no healthcare professionals (including pharmacy staff) had informed them about available recycling options. Opportunity Facilitators Study 1 identified potential physical opportunity facilitators, with older participants (who are likely to have more frequent pharmacy visits), showing a higher likelihood of returning inhalers. Survey responses also suggested that convenient disposal points within the pharmacy setting, similar to those for batteries or vapes, would encourage recycling. Similar physical opportunity facilitators were reported in Study 2 interviews for those who regularly visited the pharmacy to pick up their inhalers. Regarding social opportunity , Study 1 highlighted that public messaging could shift social norms around inhaler disposal. In Study 2, participants viewed pharmacists as trusted professionals who could play a key role in promoting inhaler recycling, emphasizing their influence in encouraging proper disposal behaviours. Table 6 presents the findings relating to factors affecting participants’ motivation for disposing of inhalers appropriately. Table 6 Mapping of barriers and facilitators from studies 1 and 2 relating to the Motivation component of the COM-B Model Motivation Commonalities Barriers identified in Study 1 survey data Barriers identified in Study 2 interview data Facilitators identified in Study 1 survey data Facilitators identified in Study 2 interview data Reflective Motivation Environmental consequences of engaging or not engaging in inhaler recycling. Only 17% of respondents were aware that disposal method affected resultant emissions. Using median values, participants underestimated the carbon footprint of MDIs by 81% and overestimated the carbon footprint DPIs by 352%. Some patients did not feel that their individual contribution to recycling inhalers would have much impact on the environment. People who said that reducing their carbon footprint was “Very important” to them were nearly three times as likely to return them. A behaviourally informed message, which directly connected inhaler disposal to carbon footprint, was significantly better at encouraging people to dispose of their inhalers correctly. About 83% said they would probably / definitely return their inhalers in future on learning it’s the method that is better for the environment. Recycling aligns with their personal goals of sustainability, and they had strong intentions to use a scheme if it is simple and exists locally, That they view recycling having a positive impact Automatic Motivation Habit formation 56% of people said they dispose of their inhalers (generally inappropriately) simply out of habit. People also don’t trust themselves to remember to return their inhalers. Of the 11% who said they would likely not dispose of their inhaler correctly, 22% of this group said they would likely forget in future. The length of time between picking up a “new” inhaler and finishing current inhaler would make it difficult to remember to recycle inhalers. 30% already attempt to recycle (incorrectly) by disposing in recycling bins Free text responses suggests that some people separate the plastics of inhalers to put what they perceive as recyclable components into recycling bin Patients were already in the habit of going to the pharmacy to pick up prescriptions was seen as positive reinforcement to recycle Some people thought providing an incentive may help people develop the habit of recycling their inhalers. Motivation Barriers Reflective motivation was a key barrier in both studies. In Study 1, only 17% of participants were aware that inhaler disposal affects carbon emissions, with many significantly underestimating the carbon footprint of metered-dose inhalers (MDIs) and overestimating that of dry powder inhalers (DPIs). Some Study 2 participants felt their individual recycling efforts would have minimal environmental impact. Additionally, the lack of pharmacist promotion of inhaler recycling was identified as a barrier. Regarding automatic motivation , 56% of Study 1 participants disposed of inhalers out of habit, typically inappropriately, and many expressed doubts about remembering to return inhalers. Study 2 highlighted that the long interval between receiving a new inhaler and finishing the current one made it difficult to remember proper disposal, further hindering recycling behaviour. Motivation Facilitators Reflective motivation facilitators in Study 1 revealed that participants who considered reducing their carbon footprint “very important” were nearly three times more likely to return inhalers to pharmacies. When informed that proper inhaler disposal benefits the environment, about 83% said they would probably or definitely recycle in the future. Behaviourally informed messages that linked inhaler disposal directly to carbon emissions were significantly more effective than standard messaging. In Study 2, reflective motivation facilitators included a belief in personal ability to recycle, strong intentions to engage if schemes were simple and local, and the view that pharmacists should actively encourage recycling as part of their professional role. Participants expressed positive attitudes toward inhaler recycling once informed, aligning it with personal sustainability goals. Regarding automatic motivation , 30% of Study 1 participants already attempted to recycle inhalers, albeit often incorrectly, such as placing parts in recycling bins at home. In Study 2, habitual pharmacy visits supported recycling behaviour, and some interviewees felt incentives might encourage habit formation, though these were not essential. DISCUSSION This paper combined datasets from two studies utilising contrasting research methodologies to explore inhaler recycling awareness and behaviours through a psychological lens drawing on behavioural models. The novel approach to merging the findings from two nations with two different health systems highlighted many commonalities regardless of the devolved nature of healthcare in Wales. The synthesis of findings highlights that patients were unaware of the need to return inhalers to pharmacies for disposal and often discarded them in domestic waste. Inhaler users viewed community pharmacies as convenient locations for recycling schemes due to their accessibility and close proximity. However, they were unlikely to engage with initiatives that require significant additional effort such as traveling out of their way to return to the inhaler. Disposal behaviours within the datasets align with existing literature indicating that most inhalers in the UK are not recycled (Sivarajasingam, 2021 , Murphy et al. 2023b , Erkskine, 2022; De Vos, 2020). In line with the findings of Murphy et al ( 2023a ) regarding awareness of the carbon footprint of improper inhaler disposal, Study 1 participants who understood the environmental impact of inhaler disposal were more than twice as likely to indicate a future intention to return their inhalers to pharmacy. Overall, both psychological and physical capability limitations hindered effective inhaler disposal, suggesting a need for clearer guidance, improved accessibility, and interventions that support habit formation. Despite strong intentions to engage with inhaler recycling in the future, inhaler users in both studies perceived that it would be challenging to form new disposal habits. This suggests that even though inhaler users exhibit a readiness to adopt new sustainable practices there maybe challenges in engaging long-term behaviour change. The formation of new recycling habits can be hindered by established routines which are resistant to change (Jager, 2023); in this case most inhaler users were disposing of their inhalers within household bins or breaking the inhalers into component parts, so that the plastic could be picked up by local kerb side recycling collections. To achieve sustained behaviour change it is important that the common barriers to recycling are addressed. Our findings underline the need for all healthcare professionals, involved in the prescribing and dispensing of inhalers to build the importance of recycling in to their conversations. Promotional messages that frame inhaler recycling as a valued, simple and accessible behaviour could help encourage inhaler users to adopt new recycling habits. Further to this, Study 1 found that behaviourally informed messages were more likely to prompt inhaler users to consider inhaler recycling compared to current NHS communications. A longitudinal study by Linder et al. ( 2018 ) trialled the use of behaviourally informed information leaflets to promote recycling in Sweden, with findings highlighting that such messaging increased pro-environmental behaviour and rates of food recycling. Limitations and strengths There are some limitations that may affect the generalisability of these findings. Convenience sampling was used in both studies which may have excluded individuals with lower health engagement or digital access. Study 1 was conducted online, relying on NHS volunteer panels, and may have biased the sample toward those with higher health literacy. The low awareness among patients about the need to return inhalers to pharmacies for disposal could have impacted their engagement in this research. Study 1 had a good response rate, but lacked geographical data to establish regional representation of participants across England, while the small sample in Study 2 had good geographical spread across Wales. Both studies explored hypothetical behaviours, such as future willingness to dispose of inhalers properly, which may not reflect actual actions due to intention–action gaps (Sheeran & Webb, 2016 ) and possible social desirability bias (Bernadi & Nash, 2023). Additionally, Study 1 compared two different message formats, but the design does not isolate which specific features (e.g., colour, wording, layout) influenced the reported intentions, limiting interpretation of the messaging effects. A strength of both studies lies the use of psychological frameworks to underpin the research where the use of two data collection methods encouraged a broader range of patients to engage with the research. The systematic exploration of the barriers and facilitators by applying a behavioural diagnosis, identified which COM-B component(s) to address in the design of an intervention to support this population of inhaler users. Free-text comments captured in Study 1 allowed further explanatory data to be elucidated, while the qualitative nature of Study 2 provided in-depth insights to the barriers and facilitators of inhaler recycling behaviours. Recommendations and further research To ensure higher uptake, future schemes must be designed in a way that ensures accessibility (e.g. placing recycling bins in convenient locations within the local community). However, public awareness of inhaler recycling remains low. Most existing schemes have been limited to a single setting, typically the pharmacy. A whole-system approach involving all patient-facing healthcare professionals and system-level changes within the broader healthcare environment is likely to be more effective in promoting lasting changes in behaviour. Behavioural insights from both studies were mapped to COM-B and were linked to their respective intervention functions on the BCW. This identified five priority areas which could support the success of future inhaler recycling schemes within community pharmacies. To establish national-level educational campaigns which highlight the environmental benefits of proper inhaler disposal (Education). To improve signposting to inhaler recycling schemes in the community, for example, posters in asthma clinics or adding recycling prompts to medication labelling, can help raise awareness and remind inhaler users to engage (Environmental Restructuring). To support sustained engagement, inhaler users should receive feedback on the environmental impact of recycling schemes (Coercion). To adopt behaviourally informed messaging to encourage inhaler users to appropriately dispose of inhalers (Persuasion). To acknowledge (or praise) those who engage in the recycling scheme (Incentivization). Future research should focus on investigating the impact of the above strategies on inhaler recycling uptake, harnessing a mixed-methods approach to identify effective interventions and reasons for their success or otherwise. CONCLUSION To maximise the impact of inhaler recycling schemes, there is a need to understand what patients currently do with their inhalers once the inhaler cartridge is empty or the inhaler is no longer needed, and to explore their attitudes and beliefs about inhaler disposal. This study highlights significant gaps in awareness and behaviour regarding proper inhaler disposal across two different healthcare contexts. Despite recognising community pharmacies as convenient disposal points, many inhaler users lack knowledge about appropriate disposal methods and often discard inhalers in household waste. While environmental concerns can motivate recycling intentions, forming new, sustained habits remains difficult. The findings underscore the need for multifaceted interventions that address psychological, physical, and social barriers. By leveraging behaviour change frameworks like COM-B and the Behaviour Change Wheel, targeted strategies—such as national education campaigns, improved signposting, feedback mechanisms, persuasive messaging, and incentivization—can enhance engagement with recycling schemes. Importantly, fostering a whole-system approach involving all healthcare professionals can support sustained behaviour change and broaden reach. Future research should focus on implementing and evaluating these interventions to identify effective methods for increasing inhaler recycling uptake. Ultimately, enhancing inhaler disposal practices can contribute to reducing the environmental impact of inhaler use and promote more sustainable healthcare behaviours. METHODS Study design and participant recruitment Study 1: Data were collected using an online quantitative survey (hosted via Qualtrics™ between 09/04/2024 and 28/04/2014) developed to assess inhaler disposal practices, willingness to return inhalers to the pharmacy and the perceived barriers and facilitators to inhaler disposal. Participant recruitment was via a study advert e-mailed to members of the NHS App and NHS Vaccine participant panels. Study 2: Barriers and facilitators to returning inhalers to the community pharmacy for recycling. The study was advertised via posters in community pharmacies and social media adverts (X™’, Facebook™) using qualitative methodology. Participants were given a £20 gift voucher. For both studies, eligible participants were inhaler users (or their guardian) aged 18 years or older, prescribed one or more MDI inhalers. Convenience sampling was adopted for both studies where participants needed to be living in England for inclusion in study 1 or one of three areas of Wales (North, Southeast and Southwest) for inclusion in study 2. Ethics Study 1: Ethical approval was not required as it met the criteria for service evaluation (Health Research Authority, 2022 ) to assess the use and public understanding of NHS recommendations for inhaler disposal, with view to delivering improvements in the quality of guidelines. Study 2: Cardiff Metropolitan University, Ethics Committee (Reference number: Sta-7736) granted ethical approval, with additional approval granted to combine the datasets of both studies for synthesis and further analysis (Reference number: sta-10739). Data Collection Study 1: A multi-stage quantitative survey (Supplementary Material 1) was designed to gather current inhaler disposal practices and views about inhaler recycling. The opportunity for free-text responses was also provided for some questions. An information sheet and eligibility screening questions were included and informed consent was captured. Eligible participants indicated from a list of options how they currently dispose of their inhalers and reasons for doing so (free text). A multiple-choice question (MCQ) assessed their understanding of NHS inhaler disposal recommendations. Following a between-participant design, half of the respondents were presented with a standard NHS message about inhaler disposal (Message A) and half a behaviourally informed message about inhaler disposal (Message B) (Fig. 3 ). Participants rated their likelihood of returning inhalers in the future on a scale of 1–7. Those scoring 4 or below were presented with specified options to select reasons for not returning inhalers in the future. Awareness of inhalers' environmental impact was assessed by asking participants to estimate how many miles they would need to drive in an average petrol car to have the same carbon footprint of a presented inhaler. Participants made these estimates for both a pressurized metered dose inhaler (MDI) and dry powder inhaler (DPI), where the order of presentation of questions was randomized. Questions regarding the types of inhalers used, guidance received on disposal, perceived importance of reducing inhaler carbon footprint, and support needed for proper future disposal were included. Basic demographic information was also collected. Study 2: One-to-one semi-structured interviews were conducted online (via MS Teams™) in Autumn 2023. An interview schedule (Supplementary Material 2) was developed based on existing literature, the COM-B model of behaviour (Michie et al, 2011 ) and Theoretical Domains Framework (TDF) (Atkins et al, 2017 ; Caine et al, 2012) as a guiding framework. Introductory questions were used to gain an understanding of inhaler users’ experiences of inhaler recycling and their knowledge of the environmental impact of inappropriate disposal of inhalers. The interviews explored perceptions of the barriers and facilitators to appropriate inhaler disposal and recycling in a community pharmacy. Interviews were audio-recorded, anonymised and transcribed verbatim for analysis (Seage et al, 2025 ). Data Analysis Study 1: All statistical analyses were carried out using RStudio Version 12.0. Descriptive statistics were generated for all recorded variables. One-sample Wilcoxon signed rank tests were used to compare reported estimated carbon footprint mileage equivalents of MDIs and DPIs to their actual mileage equivalents. A Mann-Whitney U test was used to compare likelihood of returning inhalers in the future in response to Message A vs Message B. Likelihood of returning inhalers was further modelled with a binary logistic regression using dichotomized responses, with scores from 1 to 6 on the likelihood scale coded as 0 and a score of 7 coded as 1. Robustness checks were conducted using ordinal logistic regressions. Study 2: As reported in Seage et al, ( 2025 ), framework analysis was undertaken by mapping the interview data to the COM-B model and thematic analysis of any data that was not mapped to the COM-B (Pope, Ziebland & Mays, 2000 ; Pope & Mays, 2006 ; Braun & Clark, 2006 ). Codes were applied to the framework’s pre-existing categorical themes (e.g., physical capability, psychological capability, etc.). Data from study 1 and study 2 were synthesised by mapping key findings to the COM-B components. The Behaviour Change Wheel was used to make recommendations for intervention functions that would support future behaviour change. Declarations DATA AVAILABILITY The data sets generated and/or analysed during the current study are available from the corresponding author on reasonable request. ACKNOWLEDGEMENTS Thank you to Sian Evans and Dr Angharad Wooldridge at Public Health Wales for providing oversight of Study 2 and helping with inhaler user recruitment from community pharmacies. AUTHOR CONTRIBUTIONS TMcE, TH and AB contributed to the design, conduct and data analysis for Study 1. DHJ, CHS, SB, AC and AH contributed to the design, conduct and data analysis for Study 2. DHJ, TMcE, CHS and TH synthesised the data from Studies 1 and 2 and drafted the manuscript with input from HT. All authors provided critical review of the manuscript. COMPETING INTERESTS The authors declare no competing interests. FUNDING DECLARATION There was no funding to conduct the quantitative study (Study 1). Funding was received from Public Health Wales to conduct the qualitative study (Study 2). No further funding was received to conduct the merger of findings of both studies. ADDITIONAL INFORMATION Supplementary information. The online version contains supplementary information available at References Atkins, L., Francis, J., Islam, R. et al. (2017). A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science , 12, 77. https://doi.org/10.1186/s13012-017-0605-9 Baithun C, Rooke Z, Srinivas J (2022) ‘I know where you bin’: inhaler use and disposal practices within paediatrics at Milton Keynes University Hospital Archives of Disease in Childhood ;107: A312-A313. Bernardi, R. A., & Nash, J. (2022). The importance and efficacy of controlling for social desirability response bias. Ethics & Behavior, 33(5), 413–429. https://doi.org/10.1080/10508422.2022.2093201 Braun, V., & Clark V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology . 3 (2): 77–101. Cane, J., O’Connor, D., & Michie, S. (2012). Validation of the Theoretical Domains Framework for use in behaviour change and implementation research. Implementation Science , 7, 37. Caron C, Sajwani S, Bateman K, Degenhardt O, Gaudreau-Simard M, Pakhale S, Kanji S. Environmentally sustainable opportunities for health systems: Metered-dose inhaler prescribing, dispensing, use and waste at a tertiary academic centre. Can Pharm J (Ott ). 2024;157(6):315–323. doi: 10.1177/17151635241268299. PMID: 39539595; PMCID: PMC11556618. De Vos, R., Rupani, H., Longstaff, J., Hicks, A., Fox, L., Wiffen, L., Brown, T. & Chauhan, A. (2020) Inhaler recycling prevalence in a secondary care clinic in England. European Respiratory Journal , 56, 1886. Erskine, D. (2022). Is the path to greener inhalers paved with good intentions? Drug and Therapeutics Bulletin , 60 (3), 34. https://doi.org/10.1136/dtb.2021.000048 Health Research Authority. (2022). HRA - Defining Research . https://www.hra-decisiontools.org.uk/research/docs/DefiningResearchTable_Oct2022.pdf Herrera, H., Charalambous, M., Dean, H., Youles, D., Rutter, P. & Warren, N. 2024. Patients' views and behaviours in relation to asthma inhalers use and their impact on environmental sustainability: a cross-sectional survey study. International Journal of Pharmacy Practice , 32(Supplement 1), i35. Hodge, A., Wickham, H., Florman, K., Barrowcliffe, G., Tynan, A., Patel, A., Brill, S. & Brown, J. 2024. The patient perspective on the environmental impact of inhalers. Respiratory Medicine , 235, 107864. Jager, W. (2003). Breaking “bad habits”: a dynamical perspective on habit formation and change. https://www.rug.nl/staff/w.jager/jager_habits_chapter_2003.pdf Janson C, Hernando Platz J, Soulard S, Langham S, Nicholson L, Hartgers-Gubbels ES. Reducing carbon footprint by switching to reusable soft-mist inhalers. ERJ Open Res . 2023;9(3):00543–2022. doi: 10.1183/23120541.00543-2022. PMID: 37143844; PMCID: PMC10152248. Linder, N., Lindahl, T., Lindahl, T., & Borgström, S. (2018). Using Behavioural Insights to Promote Food Waste Recycling in Urban Households-Evidence From a Longitudinal Field Experiment. Frontiers in Psychology , 9, 352. https://doi.org/10.3389/FPSYG.2018.00352 Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science , 6(1), 42. Retrieved from DOI: 10.1186/1748-5908-6-42 . Murphy A, Howlett D, Gowson A, Lewis H. (2023a) Understanding the feasibility and environmental effectiveness of a pilot postal inhaler recovery and recycling scheme. NPJ Prim Care Respir Med . 33 (1):5. doi: 10.1038/s41533-023-00327-w . PMID: 36681666; PMCID: PMC9864496 Murphy, A, Carroll, W, Gotsell M, Potter C, Quint J, Malone R. (2023b). How and when do patients dispose of old or unwanted inhalers? Thorax , 78 (Suppl 4) 10.1136/thorax-2023-BTSabstracts.P46 . Murphy A, Carroll W, Gotsell M, Potter C, Quint JK, & Malone R (2024). How do patients determine when their inhaler is empty? Insights from an analysis of returned inhalers and a patient survey. BMJ Open Respir Res. 25;11(1) NHS England (2023) NHS clinical waste strategy. Available online at https://www.england.nhs.uk/long-read/nhs-clinical-waste-strategy/ [Accessed on 01.05.25] NHS Wales (2021). https://www.gov.wales/sites/default/files/publications/2021-03/nhs-wales-decarbonisation-strategic-delivery-plan.pdf) Nurse K, Patel K, Badawy L, Chotai S, Roueche A (2022) 1015 Improving environmental sustainability of inhaler use in paediatric asthma patients Archives of Disease in Childhood 2022;107:A467-A468. Ong S, Ooi G, Shafie A, & Hassali M, (2020) Knowledge, attitude and disposing practice of unused and expired medicines among the general public in Malaysia, Journal of Pharmaceutical Health Services Research , Volume 11, Issue 2, June 2020, Pages 141–148, https://doi.org/10.1111/jphs.12333 Pope, C., Ziebland S., & Mays N. (2000). Qualitative research in health care. Analysing qualitative data. BMJ . 320 (7227): 114–116. DOI 10.1136/bmj.320.7227.114 (accessed 9/5/2024). Pope, C., & Mays. N. (2006). Qualitative research in health care. 3rd Edition. Oxford: Blackwell / BMJ. Seage C.H., Caffoor, A., Harrop, A., Wooldridge, A., Thomas H., Evans, S., Brown, S., James, D.H. (2025) Behavioural insights about barriers and facilitators to returning inhalers to the community pharmacy in Wales for safe disposal: patient and community pharmacy perspectives, International Journal of Pharmacy Practice , riaf037, https://doi.org/10.1093/ijpp/riaf037 Sheeran, P., and Webb, T. L. (2016) The Intention–Behavior Gap. Social and Personality Psychology Compass , 10: 503–518. doi: 10.1111/spc3.12265 . Sinnott, C., Mercer, S. W., Payne, R. A., Duerden, M., Bradley, C. P., & Byrne, M. (2015). Improving medication management in multimorbidity: development of the Multimorbidity Collaborative Medication Review and Decision making (MY COMRADE) intervention using the Behaviour Change Wheel. Implementation Science, 10(1), 132. Retrieved from DOI: 10.1186/s13012-015-0322-1 . Sivarajasingam, V. (2021). Understanding patients’ knowledge of inhaler recycling. BJGP Life .https://bjgplife.com/understanding-patients-knowledge-of-inhalerrecycling/( 2021) The Pharmaceutical Journal, PJ, June 2019, 302, 7926:302(7926) DOI: 10.1211/PJ.2019.20206619. Breath of fresh air: why it is time for a national drive to recycle used inhalers - The Pharmaceutical Journal (accessed 12/6/2025). The Pharmaceutical Journal, PJ, April 2025, 314, 996: 314 (7996): DOI:10.1211/PJ2025.1.353017. NHS England to assess feasibility of a national inhaler recycling scheme - The Pharmaceutical Journal (accessed 12/6/2025). Wajid S, Siddiqui N, Mothana R, Samreen S. (2020) Prevalence and Practice of Unused and Expired Medicine-A Community-Based Study among Saudi Adults in Riyadh, Saudi Arabia. Biomed Res Int . 2020;2020:6539251. doi: 10.1155/2020/6539251 . PMID: 32724806; PMCID: PMC7364235. Walpole S, Fitzpatric A, Moffatt K, Smith K, Potts A, Doe S, Burns G, Tedd H (2021) P187 Ease of use, effectiveness and environmental impacts: Evaluating inhaler prescriptions, patient preferences and opportunities for improvement. Thorax 2021;76:A190-A191. Wilkinson AJK, Braggins R, Steinbach I, et al ( 2019) Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England BMJ Open 2019;9:e028763. doi: 10.1136/bmjopen-2018-028763 Additional Declarations No competing interests reported. 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2011)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7179716/v1/0bd67907dac5534ad236e100.png"},{"id":88236800,"identity":"54e398d1-1a4c-449b-937c-d507c2ee44f5","added_by":"auto","created_at":"2025-08-04 10:27:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114794,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eThe COM-B model – a framework for understanding behaviour (Michie, 2011)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7179716/v1/cbe5f0891f9f212d69df07d9.png"},{"id":88235825,"identity":"989eda04-2e07-4656-b293-f625d6e5b453","added_by":"auto","created_at":"2025-08-04 10:19:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":279010,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMessage A (left), based on current NHS communications and Message B (right).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7179716/v1/ccbbb7431a258d9bf7957b61.png"},{"id":88238209,"identity":"ed370ed3-187a-4e41-94cd-41e5eacc1228","added_by":"auto","created_at":"2025-08-04 10:43:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2273744,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7179716/v1/8eb3deb7-06b4-4fb5-9389-a9abb8667312.pdf"},{"id":88235821,"identity":"4b64de37-9fd1-427f-957e-c776e44878bb","added_by":"auto","created_at":"2025-08-04 10:19:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":31467,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7179716/v1/1039b168b82cc54dba568b39.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient Attitudes, Beliefs, and Practices in Environmentally Friendly Inhaler Disposal: A Mixed-Methods Evaluation with Behaviourally Informed Recommendations","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBy 2026, the National Health Service (NHS) is expected to deliver a 50% reduction in carbon emissions produced from waste management (NHS England, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e) rising to 80% by 2028\u0026ndash;2032 (NHS England, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; NHS Wales, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Metered dose inhalers (MDIs) are one of the greatest single contributors to carbon emissions across the NHS (Wilkinson et al, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Erskine, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e) since they contain hydrofluorocarbon (HFCs) propellants, estimated to account for 4% of all NHS carbon dioxide (CO\u003cem\u003e2)\u003c/em\u003e emissions. One estimate is that 73\u0026nbsp;million inhalers are dispensed every year (The Pharmaceutical Journal, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). There is a lack of data regarding the current disposal behaviours of inhaler users. Various initiatives have been proposed to reduce the significant global warming impact from inappropriate MDI disposal (Murphy et al, \u003cspan class=\"CitationRef\"\u003e2023a\u003c/span\u003e) involving prescribing less inhalers (Caron et al, \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; ), switching to a non-HFC inhaler (Janson et al, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wilkinson et al, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e) or the implementation of recycling schemes (Murphy et al, \u003cspan class=\"CitationRef\"\u003e2023a\u003c/span\u003e; Seage et al, \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). Inhaler recycling involves collection and disposal of MDIs by a specialist waste contractor where the plastic, metal and gas are recovered and reused. This inhaler recycling technology has already been successfully used in a small number of trials run by NHS Trusts across England and Wales and in projects run by two major pharmaceutical companies (The Pharmaceutical Journal, \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). One example is a project that took place in community pharmacies and hospitals across Leicestershire, England, estimated to have saved the equivalent of 305.3 tonnes of CO\u003csub\u003e2\u003c/sub\u003e emissions from entering the atmosphere where 52,148 inhalers were received via postal return over a 24-month period (Murphy et al, \u003cspan class=\"CitationRef\"\u003e2023a\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTo our knowledge there are currently no centralised national schemes in place in the UK utilising this or alternative approaches to dispose of these inhalers in an environmentally friendly way. Patients are encouraged to return all unused and empty inhaler canisters (along with all other unwanted medicines) to the community pharmacy for safe disposal. Currently, these are incinerated along with all returned medicinal waste; however, the temperatures are not high enough to prevent carbon emissions from the MDIs, even if the canisters are empty, therefore still contributing to carbon emissions. The future implementation of a community pharmacy inhaler recycling scheme relies on engaging with patients to encourage environmentally friendly inhaler disposal.\u003c/p\u003e\n\u003cp\u003eSeveral studies highlight limited public awareness regarding the environmental impact of inhalers. Hodge et al. (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) found that 71% of inhaler users (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;61) were unaware that inhalers contain greenhouse gases. Similarly, over 80% of patients recruited from UK hospitals and GP practices were unaware that inhalers could be recycled (Sivarajasingam, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). While a high proportion of users (93%) expressed a desire for more environmental information about MDIs (Herrera et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), fewer than 15% of healthcare professionals routinely discussed inhaler recycling with their patients (Walpole et al., 2020).\u003c/p\u003e\n\u003cp\u003eOther studies have shown that despite low initial awareness, many patients are open to more sustainable practices, expressing a willingness to recycle if accessible facilities are made available (Baithun et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Murphy et al\u0026rsquo;s (\u003cspan class=\"CitationRef\"\u003e2023a\u003c/span\u003e) pilot postal return scheme showed high patient satisfaction, but initial uptake was slow, gradually increasing over time. Broader engagement with recycling initiatives remains limited. In a secondary care clinic, only 35% of patients (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;261) recycled their inhalers over six months, while 57% continued to dispose of them in the household waste (De Vos et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). In paediatric and community settings, educational efforts improved awareness of the need to recycle inhalers, however, consistent engagement with recycling schemes remained a challenge (Nurse et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). International studies echo these trends, with improper disposal practices remaining prevalent despite media advertisements or financial incentives being used to influence behaviour (Ong et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; Wajid, 2020). Further to this, Murphy et al (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e) reported that over half of patients (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;16/29; 55%) using an inhaler without a dose counter did not have the confidence to determine when their inhaler was empty; resulting in inhalers being returned either under or over-used.\u003c/p\u003e\n\u003cp\u003eAcross the existing literature, there is consensus that patient and staff education, availability of recycling points, and clearer communication from healthcare providers and pharmaceutical companies are essential. Incorporating recycling advice during consultations and leveraging general practice settings can significantly improve inhaler disposal practices, helping reduce environmental impact and supporting NHS sustainability goals. However, before effective solutions can be proposed, we need to understand the current behaviours, beliefs and attitudes of inhaler users towards environmentally friendly disposal. For this paper, the terms \u0026lsquo;appropriate inhaler recycling,\u0026rsquo; \u0026lsquo;appropriate inhaler disposal\u0026rsquo; and \u0026lsquo;environmentally friendly disposal\u0026rsquo; refer to the behaviour of taking the used (or unused) inhaler back to the community pharmacy or engaging in an alternative inhaler recycling scheme such as the postal initiative described earlier.\u003c/p\u003e\n\u003cp\u003eIn this paper, we present a synthesis of the findings of two studies, conducted independently of each other, adopting two contrasting methodological approaches to assess the current rates of appropriate inhaler disposal and attitudes and beliefs about inhaler recycling, mapping our findings to the COM-B Model of behaviour. The first study was a quantitative evaluation of people\u0026rsquo;s awareness of the environmental impact of inhalers, their current inhaler disposal behaviours, and the factors impacting appropriate current and future inhaler disposal. The objectives were to: i) assess current rates of appropriate inhaler disposal (i.e. return to the pharmacy or engage with another recycling scheme), explore attitudes and beliefs about inhaler disposal; (ii) examine the awareness of the environmental impact of inhalers in general, and the environmental impact of inappropriate disposal (i.e. not returning to a pharmacy or following or engaging with a recycling scheme); and (iii) test the impact of different messaging on willingness to return inhalers to pharmacy. The second study was a qualitative evaluation of patients\u0026rsquo; perspectives on returning used or unused inhalers to a community pharmacy. The aim of the study was to explore the perceived barriers and facilitators to appropriate inhaler disposal (i.e. returning to a pharmacy or engaging with another recycling scheme). Both studies were underpinned by a behavioural insights approach based on two inter-related psychological frameworks \u0026ndash; the Behaviour Change Wheel (BCW) and the COM-B (Capability, Opportunity, Motivation) model of behaviour (Michie et al, \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Behaviour Change Wheel\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe COM-B components lie at the core of the BCW, enabling outputs to be mapped to appropriate intervention functions. The BCW was developed to improve the design and implementation of behaviour change interventions (Michie et al, \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e) by providing a method of characterising interventions and linking them to target behaviours. The policy categories on the outer circle of the BCW are key to influencing change and are essential considerations for successful interventions (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe COM-B model allows the barriers to specific behaviours (i.e. environmentally friendly inhaler disposal) to be systematically explored (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The COM-B model is based on the concept that the interaction between several components, namely, the individual\u0026rsquo;s capability (C), opportunity (O) and motivation (M) can provide an explanation for why a particular behaviour (B) is or is not performed (Sinnott et al, \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e). For an intervention to be successful, one or more of these components need to be targeted for sustained behaviour change to occur.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims and objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this paper is to synthesise the findings from two independent studies to assess current inhaler users\u0026rsquo; attitudes, beliefs, and practices related to inhaler disposal. To achieve this aim, the following objectives were set:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eTo compare the findings from two studies to identify barriers and facilitators to appropriate inhaler disposal and synthesise the data by mapping to the COM-B model of behaviour.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eTo map the synthesis of findings from both studies to the BCW to make behaviourally informed recommendations to support appropriate inhaler disposal behaviours.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the relevant demographic and clinical characteristics of participants for both studies and their inhaler related practices.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of key participant characteristics for Studies 1 and 2\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy 1 (Quantitative)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudy 2 (Qualitative)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of participants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1,354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale: 528 (39%)\u003c/p\u003e\u003cp\u003eFemale: 812 (60%)\u003c/p\u003e\u003cp\u003eOther: 14 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale: 7 (64%)\u003c/p\u003e\u003cp\u003eFemale: 4 (36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u0026thinsp;=\u0026thinsp;18\u0026ndash;95 years\u003c/p\u003e\u003cp\u003eMean\u0026thinsp;=\u0026thinsp;60.9 years\u003c/p\u003e\u003cp\u003e(SD\u0026thinsp;=\u0026thinsp;13.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange\u0026thinsp;=\u0026thinsp;18\u0026ndash;65 years\u003c/p\u003e\u003cp\u003eNo mean available\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite: 91%\u003c/p\u003e\u003cp\u003eBlack: 2.5%\u003c/p\u003e\u003cp\u003eAsian: 2.5%\u003c/p\u003e\u003cp\u003eOther: 4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWhite: 9 (82%)\u003c/p\u003e\u003cp\u003eBlack: 2 (18%)\u003c/p\u003e\u003cp\u003eAsian: 0 (0%)\u003c/p\u003e\u003cp\u003eOther: 0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInhaler user / Guardian\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInhaler user\u0026thinsp;=\u0026thinsp;1,237 (91%)\u003c/p\u003e\u003cp\u003eGuardian\u0026thinsp;=\u0026thinsp;117 (9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInhaler user\u0026thinsp;=\u0026thinsp;10 (91%)\u003c/p\u003e\u003cp\u003eGuardian\u0026thinsp;=\u0026thinsp;1 (9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiagnosis*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAsthma: 1029 (76%)\u003c/p\u003e\u003cp\u003eCOPD: 298 (22%)\u003c/p\u003e\u003cp\u003eOther: 122 (9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot ascertained\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInhaler types*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMDI\u0026thinsp;=\u0026thinsp;1137 (84%)\u003c/p\u003e\u003cp\u003eDPI\u0026thinsp;=\u0026thinsp;433 (32%)\u003c/p\u003e\u003cp\u003eSMI\u0026thinsp;=\u0026thinsp;108 (8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMDIs\u0026thinsp;=\u0026thinsp;11 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCurrently return inhalers to pharmacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e284 (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (9.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAwareness of\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cb\u003eCarbon footprint changes (Study 1)**\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eExistence of recycling schemes (Study 2)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eNeed for recycling (Study 2)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199/1153 (17%)\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Some inhaler users had a diagnosis of both asthma and COPD or prescribed more than one type of inhaler which accounts totals over 100%. **Denominator lower due to attrition in survey respondent numbers. MDI\u0026thinsp;=\u0026thinsp;metered dose inhaler, DPI\u0026thinsp;=\u0026thinsp;dry powder inhaler; SMI\u0026thinsp;=\u0026thinsp;soft mist inhaler\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy 1: Quantitative study \u0026ndash; survey of inhaler disposal beliefs and practices\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSample characteristics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA sample comprising 1,354 participants took part in the survey, of which 91% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1237) were inhaler users and 9% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;117) were guardians (parents or carers) of patients prescribed inhalers. Of these, 60% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;812) were female, 39% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;528) were male and 1% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;14) identified as other. The mean age of participants was 60.9 years (SD\u0026thinsp;=\u0026thinsp;13.85). Of the sample, 76% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1029) reported being diagnosed with asthma, 22% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;298) with COPD (some reported a diagnosis of both) and 9% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;122) were prescribed an inhaler for another long-term respiratory condition. Of inhaler types, 84% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1137) were prescribed an MDI, 32% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;433) a DPI and 8% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;108) an SMI.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAwareness of environmental impact of inhalers\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOnly 17% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;230) of participants responded that they were aware of the carbon footprint associated with inappropriate inhaler disposal. When tasked with estimating the carbon footprint of an MDI relative to miles driven in a standard petrol car, participants significantly underestimated the carbon footprint, with a median response of 20 miles compared to the actual mileage equivalent of approximately 107 miles (\u003cem\u003er\u003c/em\u003e = -0.44, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.001). Participants also significantly overestimated the relative carbon footprint of DPIs, with a median estimate of 10 miles compared to the actual equivalent of approximately 2 miles (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.70, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cem\u003eCurrent disposal awareness and practices\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOf the sample, 79% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1070) failed to return their inhalers to their local pharmacy with 44% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;596) reporting that they dispose of them in the general waste, and 29% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;393) disposing them in their standard recycling bin. When asked how they thought the NHS recommends they dispose of their inhalers, 70% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;948) of participants failed to correctly identify the pharmacy as the appropriate channel for disposal.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFacilitators and barriers to appropriate current and future inhaler disposal\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhen asked why they disposed of their inhalers in the way they currently did most 56% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;758) indicated that they simply did it out of habit, with only 30% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;406) thinking that they were using the correct method. Nearly three-quarters of participants (74%; \u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1002) indicated that they had never received any guidance on how to dispose of their inhalers properly.\u003c/p\u003e\u003cp\u003eThe desire to adopt pro-environmental behaviours was high, with 84% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1137) indicating that reducing their carbon footprint was either \u0026ldquo;Important\u0026rdquo; or \u0026ldquo;Very important\u0026rdquo; to them. When presented with messaging encouraging appropriate inhaler disposal, participants showed a high likelihood to return their inhalers to the pharmacy in future (Mean likelihood score\u0026thinsp;=\u0026thinsp;6.24 out of 7, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04). Participants who saw a behaviourally informed message, specifically designed for the study (Message B, Mean likelihood score\u0026thinsp;=\u0026thinsp;6.31, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05), were significantly (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19588.50, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.008) more likely to return their inhalers than those who saw messaging based on current NHS communications (Message A, mean\u0026thinsp;=\u0026thinsp;6.17, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0 .05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThose who indicated they were unlikely to return their inhalers to the pharmacy in the future (10.7%, \u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;143/1333) were also asked for their primary reasons. The most frequently reported reason (38%; \u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;54/143) was related to the additional effort needed to return inhalers to the pharmacy. Other reasons cited as key barriers to appropriate disposal were forgetfulness (22%; \u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;31/143) and recognising that changing their existing disposal habits might be challenging (13%; \u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;19/143).\u003c/p\u003e\u003cp\u003e\u003cem\u003ePredictors of inhaler disposal by returning to the pharmacy\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSeveral factors significantly predicted whether participants reported the maximum likelihood of returning their inhalers to the pharmacy in future (χ\u003csup\u003e2\u003c/sup\u003e(17)\u0026thinsp;=\u0026thinsp;136.97, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001). Those who saw Message B were significantly more likely to return their inhalers to the pharmacy in the future (\u003cem\u003eOR\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1.61, 95% \u003cem\u003eCI =\u003c/em\u003e [1.04, 2.50], \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.033). Participants who indicated that reducing their carbon footprint was \u0026ldquo;Very important\u0026rdquo; were more likely to return their inhalers to the pharmacy in the future (\u003cem\u003eOR\u0026thinsp;=\u003c/em\u003e\u0026thinsp;6.75, 95% \u003cem\u003eCI =\u003c/em\u003e [4.06, 11.77], \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.001). Those who currently returned their inhalers to the pharmacy were more likely to continue to return them in future (\u003cem\u003eOR\u0026thinsp;=\u003c/em\u003e\u0026thinsp;28.07, 95% \u003cem\u003eCI =\u003c/em\u003e [5.46, 516.84], \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy 2: Qualitative study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA sample of eleven patients from three geographic areas of Wales were recruited to the study, seven (64%) males and four (36%) females aged between 18\u0026ndash;65 years old, of which ten (91%) were inhaler users and one (9%) was a guardian for someone prescribed an inhaler. Most participants were white (82%) ethnicity, and two participants were black. The reason for prescribing an inhaler was not ascertained for this sample. All were prescribed an MDI. None of the participants were aware that inhalers should be returned to the pharmacy for safe disposal and none had experience of using an inhaler recycling scheme.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides illustrative quotes for each theme relating to barriers for inhaler recycling in the pharmacy. Three themes were identified relating to barriers to safe disposal of inhaler medication by returning to a community pharmacy. These were: Theme 1 \u0026ndash; \u0026lsquo;I'm not going out of my way\u0026rsquo;; Theme 2 \u0026ndash; \u0026lsquo;No-one told us\u0026rsquo;, and Theme 3 \u0026ndash; \u0026lsquo;Will it really make a difference?\u0026rsquo;. Similarly, three themes were identified from the participant transcripts relating to enablers for the safe disposal of inhaler medication (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These were: Theme 1 - \u0026lsquo;Recycling aligns with my values\u003cem\u003e\u0026rsquo;\u003c/em\u003e; Theme 2 \u0026ndash;\u0026rsquo;\u003cem\u003eI already recycle, so it shouldn't be a problem\u003c/em\u003e\u0026rsquo; and Theme 3 - \u0026lsquo;\u003cem\u003eHow hard can it be?\u003c/em\u003e\u0026rsquo;. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides illustrative quotes for each theme relating to inhaler recycling in the pharmacy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSynthesis of findings from Studies 1 and 2.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e to \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e present the mapping of the barriers and facilitators from studies 1 and 2 to the COM-B Model components, highlighting the commonalities across the data sets. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the findings relating to factors affecting participants\u0026rsquo; capability of disposing of inhalers appropriately.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBarriers to returning inhalers for recycling in the pharmacy: Illustrative quotes from qualitative interviews (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;11)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 1 - \u0026lsquo;I'm not going out of my way\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTheme 2 - \u0026lsquo;No-one told us\u0026rsquo;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTheme 3 - \u0026lsquo;Will it really make a difference?\u0026rsquo;\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eAnything extra, people are less likely to do because you are likely to forget\u003c/em\u003e\u0026rdquo; (P2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I've been taking pumps for 40 years now, longer than I'd care to admit, but it has never been pointed out to me that I could take the empty inhaler back to the pharmacy. And I've been through four or five pharmacies \u0026hellip;just mention to people as they're picking things up, you know\u0026hellip;. you would argue it probably isn\u0026rsquo;t a huge thing to just say \u0026lsquo;you can drop these things back here, bring your old ones back and we\u0026rsquo;ll give you your new one\u0026rsquo; or whatever.\u0026rdquo;\u003c/em\u003e (P1).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Personally, I don't think it'll have much of an individual impact, if I recycle them or not, but I think with others it definitely will\u0026rdquo;\u003c/em\u003e (P3).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You can't take the old one in when you pick up the new one. So, you'd have to make, you'd almost have to make a special trip\u0026rdquo;\u003c/em\u003e (P1).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t think I've actually been told by a pharmacist that you can take anything back\u0026rdquo;\u003c/em\u003e (P1).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, the problem is that something like an inhaler, it seems so small and. You know, you look at the amount of recycling that you put out on a weekly basis and the amount of bin bags that people put out. Recycling, what you know, an inhaler once a month... I know it's important, but you will struggle to persuade people that it's important\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, when you're tidying up, you think, oh, just chucking it in the bin, chucking it in the recycling. So yeah, that's the problem.\u0026rdquo; (\u003c/em\u003eP2).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have asked and several others, you know, how do we dispose of inhalers? Have you got a scheme? And they sort of just look at me blank sort of well no just put them in the bin and that's it\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Before I saw your study, I had literally not thought about this\u0026hellip;\u0026rdquo; (P7).\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;in my pharmacy, personally, I don\u0026rsquo;t really see any posters or leaflets anywhere\u0026rdquo;\u003c/em\u003e (P1).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEnablers to returning inhalers for recycling in the pharmacy: Illustrative quotes from qualitative interviews (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;11)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 1 \u0026ndash; \u0026lsquo;Recycling aligns with my values\u0026rsquo;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTheme 2 - \u0026rsquo;\u003cem\u003eI already recycle, so it shouldn't be a problem\u003c/em\u003e\u0026rsquo;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTheme 3 - \u0026lsquo;\u003cem\u003eHow hard can it be?\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eI think it's definitely important to take them where they need to go and recycle them properly\u0026rdquo;\u003c/em\u003e (P1).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah. cause we recycle everything else. We pride ourselves on the fact. And you know, we're a family of four. And every fortnight we take out half a bin bag\u0026rdquo;\u003c/em\u003e (P2).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI have to pick mine up from the pharmacy anyway. So, you know, it really doesn't get much easier than that\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would be using it regardless of whether I get a reward or not; obviously it\u0026rsquo;s a nice benefit, but\u0026rdquo;\u0026hellip;\u003c/em\u003e (P3).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I like to make sure that I do recycle and stay up, stay up on sustainability\u0026rdquo;\u003c/em\u003e (P4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e. \u003cem\u003e\u0026ldquo;I wouldn't have thought so. I should imagine it would be simply in a matter of handing them over\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I'm quite big on not using propellant as much as possible\u0026rdquo;\u003c/em\u003e (P5).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Once a month we go there, so simply take anything that isn't used and isn't going to be used.\u003c/em\u003e (P5).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI do generally try to dispose of all my waste correctly and recycle if possible. So shouldn't really be any different for the inhaler\u0026rdquo;\u003c/em\u003e (P3).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMapping of barriers and facilitators from studies 1 and 2 relating to the Capability component of the COM-B Model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCapability\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommonalities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBarriers identified in Study 1 survey data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBarriers identified in Study 2 interview data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFacilitators identified in Study 1 survey data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacilitators identified in Study 2 Interview data\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePsychological Capability\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKnowledge and awareness of the need for appropriate inhaler disposal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70% of participants did not know that the NHS recommends returning their inhaler to the pharmacy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParticipants were unaware that inhalers could/or should be recycled.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eParticipants who knew how they are supposed to dispose of inhalers were over 16 times more likely to return them to the pharmacy\u003c/p\u003e\u003cp\u003eParticipants who were aware that the method of inhaler disposal impacted emissions were over twice as likely to return them to the pharmacy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysical Capability\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysical effort and skill needed to dispose of inhalers appropriately\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFor the 11% of patients who said they would not return their inhalers in the future, 38% highlighted the additional effort required as a barrier.\u003c/p\u003e\u003cp\u003eFree-text responses highlighted that some patients were not capable of making necessary visits to the pharmacy independently.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParticipants perceived themselves to not have the skills needed to be able to recycle inhalers correctly at home.\u003c/p\u003e\u003cp\u003eAdditional effort needed to plan additional journeys to the pharmacy to return inhalers for recycling.\u003c/p\u003e\u003cp\u003eReliance on public transport to travel to get to the pharmacy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParticipants felt that they would have the necessary skills to return inhalers to the pharmacy.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCapability Barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBoth studies identified \u003cem\u003epsychological and physical capability\u003c/em\u003e as key barriers to appropriate inhaler disposal. A major issue was low awareness or complete lack of knowledge about the need to recycle inhalers, along with insufficient guidance on how to do so. In Study 2, further \u003cem\u003epsychological capability\u003c/em\u003e barriers included lack of attention to pharmacy return schemes, forgetting to recycle, and difficulty forming new recycling habits. \u003cem\u003ePhysical capability\u003c/em\u003e barriers were also common. Participants in both studies cited the extra effort required to travel to a pharmacy as a deterrent, with some in Study 1 unable to make the trip independently. In Study 2, reliance on public transport was highlighted as an additional challenge. Participants also reported lacking the skills to correctly identify which parts of the inhaler could be recycled at home.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCapability Facilitators\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudy 1 found that \u003cem\u003epsychological capability\u003c/em\u003e significantly influenced inhaler disposal: participants who knew how to dispose of inhalers were over 16 times more likely to return them to the pharmacy, and those aware of the environmental impact were over twice as likely. Study 2 did not identify any \u003cem\u003epsychological capability\u003c/em\u003e facilitators. For \u003cem\u003ephysical capability\u003c/em\u003e, Study 2 interviews suggested that knowing which parts of the inhaler to recycle and being able to travel to the pharmacy without extra effort would support appropriate disposal. No \u003cem\u003ephysical capability facilitators\u003c/em\u003e were identified in Study 1 survey data, highlighting contrasting facilitator reporting across studies.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the findings relating to factors affecting participants\u0026rsquo; opportunity of disposing of inhalers appropriately.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eMapping of barriers and facilitators from studies 1 and 2 relating to the Opportunity component of the COM-B Model\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpportunity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommonalities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBarriers identified in Study 1 survey data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBarriers identified in Study 2 interview data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFacilitators identified in Study 1 survey data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacilitators identified in Study 2 interview data\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysical Opportunity\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUse of the pharmacy setting for recycling inhalers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSome free-text responses highlighted that the pharmacy is too far away or not open at convenient hours.\u003c/p\u003e\u003cp\u003eSome pharmacies do not currently offer an inhaler disposal service.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParticipants who use small, independent pharmacies perceived that their local pharmacy would not have the time, space, or resources to run a recycling scheme.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOlder participants were more likely to return inhalers, likely reflecting that they had more regular visits to pharmacy and so.\u003c/p\u003e\u003cp\u003eFree-text responses indicated that convenient disposal points would encourage them to recycle.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInhaler users regularly visit the pharmacy and did not see handing inhalers back for recycling as onerous.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSocial Opportunity\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthcare professionals as a source of advice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74% said they\u0026rsquo;d never received any guidance, with 6% not recalling if they were given any guidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParticipants stated that healthcare professionals had not informed them about how to dispose of inhalers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePublic messaging around this topic could shift social norms and expectations around proper disposal.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePharmacists viewed as an appropriate professional role to encourage engagement with inhaler recycling,\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOpportunity Barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePhysical opportunity\u003c/em\u003e was a significant barrier in both studies. Study 1 participants cited issues such as pharmacies being too far away, having limited opening hours, or not offering disposal services. In Study 2, those using small, independent pharmacies felt their local providers lacked the time, space, or resources to support inhaler recycling, with limited capacity emerging as a key theme. \u003cem\u003eSocial opportunity\u003c/em\u003e barriers were also evident. Across both studies, a major issue was the absence of advice from healthcare professionals on proper inhaler disposal. Over 80% of survey respondents in Study 1 reported not receiving or recalling any guidance, and participants in Study 2 consistently stated that no healthcare professionals (including pharmacy staff) had informed them about available recycling options.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOpportunity Facilitators\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudy 1 identified potential \u003cem\u003ephysical opportunity\u003c/em\u003e facilitators, with older participants (who are likely to have more frequent pharmacy visits), showing a higher likelihood of returning inhalers. Survey responses also suggested that convenient disposal points within the pharmacy setting, similar to those for batteries or vapes, would encourage recycling. Similar \u003cem\u003ephysical opportunity\u003c/em\u003e facilitators were reported in Study 2 interviews for those who regularly visited the pharmacy to pick up their inhalers. Regarding \u003cem\u003esocial opportunity\u003c/em\u003e, Study 1 highlighted that public messaging could shift social norms around inhaler disposal. In Study 2, participants viewed pharmacists as trusted professionals who could play a key role in promoting inhaler recycling, emphasizing their influence in encouraging proper disposal behaviours.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents the findings relating to factors affecting participants\u0026rsquo; motivation for disposing of inhalers appropriately.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eMapping of barriers and facilitators from studies 1 and 2 relating to the Motivation component of the COM-B Model\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotivation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommonalities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBarriers identified in Study 1 survey data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBarriers identified in Study 2 interview data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFacilitators identified in Study 1 survey data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacilitators identified in Study 2 interview data\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eReflective Motivation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnvironmental consequences of engaging or not engaging in inhaler recycling.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOnly 17% of respondents were aware that disposal method affected resultant emissions.\u003c/p\u003e\u003cp\u003eUsing median values, participants underestimated the carbon footprint of MDIs by 81% and overestimated the carbon footprint DPIs by 352%.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSome patients did not feel that their individual contribution to recycling inhalers would have much impact on the environment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePeople who said that reducing their carbon footprint was \u0026ldquo;Very important\u0026rdquo; to them were nearly three times as likely to return them.\u003c/p\u003e\u003cp\u003eA behaviourally informed message, which directly connected inhaler disposal to carbon footprint, was significantly better at encouraging people to dispose of their inhalers correctly.\u003c/p\u003e\u003cp\u003eAbout 83% said they would probably / definitely return their inhalers in future on learning it\u0026rsquo;s the method that is better for the environment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRecycling aligns with their personal goals of sustainability, and they had strong intentions to use a scheme if it is simple and exists locally,\u003c/p\u003e\u003cp\u003eThat they view recycling having a positive impact\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAutomatic Motivation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHabit formation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56% of people said they dispose of their inhalers (generally inappropriately) simply out of habit.\u003c/p\u003e\u003cp\u003ePeople also don\u0026rsquo;t trust themselves to remember to return their inhalers. Of the 11% who said they would likely not dispose of their inhaler correctly, 22% of this group said they would likely forget in future.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThe length of time between picking up a \u0026ldquo;new\u0026rdquo; inhaler and finishing current inhaler would make it difficult to remember to recycle inhalers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30% already attempt to recycle (incorrectly) by disposing in recycling bins\u003c/p\u003e\u003cp\u003eFree text responses suggests that some people separate the plastics of inhalers to put what they perceive as recyclable components into recycling bin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePatients were already in the habit of going to the pharmacy to pick up prescriptions was seen as positive reinforcement to recycle\u003c/p\u003e\u003cp\u003eSome people thought providing an incentive may help people develop the habit of recycling their inhalers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMotivation Barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eReflective motivation\u003c/em\u003e was a key barrier in both studies. In Study 1, only 17% of participants were aware that inhaler disposal affects carbon emissions, with many significantly underestimating the carbon footprint of metered-dose inhalers (MDIs) and overestimating that of dry powder inhalers (DPIs). Some Study 2 participants felt their individual recycling efforts would have minimal environmental impact. Additionally, the lack of pharmacist promotion of inhaler recycling was identified as a barrier. Regarding \u003cem\u003eautomatic motivation\u003c/em\u003e, 56% of Study 1 participants disposed of inhalers out of habit, typically inappropriately, and many expressed doubts about remembering to return inhalers. Study 2 highlighted that the long interval between receiving a new inhaler and finishing the current one made it difficult to remember proper disposal, further hindering recycling behaviour.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMotivation Facilitators\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eReflective motivation\u003c/em\u003e facilitators in Study 1 revealed that participants who considered reducing their carbon footprint \u0026ldquo;very important\u0026rdquo; were nearly three times more likely to return inhalers to pharmacies. When informed that proper inhaler disposal benefits the environment, about 83% said they would probably or definitely recycle in the future. Behaviourally informed messages that linked inhaler disposal directly to carbon emissions were significantly more effective than standard messaging. In Study 2, \u003cem\u003ereflective motivation\u003c/em\u003e facilitators included a belief in personal ability to recycle, strong intentions to engage if schemes were simple and local, and the view that pharmacists should actively encourage recycling as part of their professional role. Participants expressed positive attitudes toward inhaler recycling once informed, aligning it with personal sustainability goals. Regarding \u003cem\u003eautomatic motivation\u003c/em\u003e, 30% of Study 1 participants already attempted to recycle inhalers, albeit often incorrectly, such as placing parts in recycling bins at home. In Study 2, habitual pharmacy visits supported recycling behaviour, and some interviewees felt incentives might encourage habit formation, though these were not essential.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis paper combined datasets from two studies utilising contrasting research methodologies to explore inhaler recycling awareness and behaviours through a psychological lens drawing on behavioural models. The novel approach to merging the findings from two nations with two different health systems highlighted many commonalities regardless of the devolved nature of healthcare in Wales. The synthesis of findings highlights that patients were unaware of the need to return inhalers to pharmacies for disposal and often discarded them in domestic waste. Inhaler users viewed community pharmacies as convenient locations for recycling schemes due to their accessibility and close proximity. However, they were unlikely to engage with initiatives that require significant additional effort such as traveling out of their way to return to the inhaler.\u003c/p\u003e\u003cp\u003eDisposal behaviours within the datasets align with existing literature indicating that most inhalers in the UK are not recycled (Sivarajasingam, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Murphy et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e, Erkskine, 2022; De Vos, 2020). In line with the findings of Murphy et al (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e) regarding awareness of the carbon footprint of improper inhaler disposal, Study 1 participants who understood the environmental impact of inhaler disposal were more than twice as likely to indicate a future intention to return their inhalers to pharmacy. Overall, both \u003cem\u003epsychological and physical capability\u003c/em\u003e limitations hindered effective inhaler disposal, suggesting a need for clearer guidance, improved accessibility, and interventions that support habit formation.\u003c/p\u003e\u003cp\u003eDespite strong intentions to engage with inhaler recycling in the future, inhaler users in both studies perceived that it would be challenging to form new disposal habits. This suggests that even though inhaler users exhibit a readiness to adopt new sustainable practices there maybe challenges in engaging long-term behaviour change. The formation of new recycling habits can be hindered by established routines which are resistant to change (Jager, 2023); in this case most inhaler users were disposing of their inhalers within household bins or breaking the inhalers into component parts, so that the plastic could be picked up by local kerb side recycling collections. To achieve sustained behaviour change it is important that the common barriers to recycling are addressed. Our findings underline the need for all healthcare professionals, involved in the prescribing and dispensing of inhalers to build the importance of recycling in to their conversations. Promotional messages that frame inhaler recycling as a valued, simple and accessible behaviour could help encourage inhaler users to adopt new recycling habits. Further to this, Study 1 found that behaviourally informed messages were more likely to prompt inhaler users to consider inhaler recycling compared to current NHS communications. A longitudinal study by Linder et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) trialled the use of behaviourally informed information leaflets to promote recycling in Sweden, with findings highlighting that such messaging increased pro-environmental behaviour and rates of food recycling.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and strengths\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere are some limitations that may affect the generalisability of these findings. Convenience sampling was used in both studies which may have excluded individuals with lower health engagement or digital access. Study 1 was conducted online, relying on NHS volunteer panels, and may have biased the sample toward those with higher health literacy. The low awareness among patients about the need to return inhalers to pharmacies for disposal could have impacted their engagement in this research. Study 1 had a good response rate, but lacked geographical data to establish regional representation of participants across England, while the small sample in Study 2 had good geographical spread across Wales. Both studies explored hypothetical behaviours, such as future willingness to dispose of inhalers properly, which may not reflect actual actions due to intention\u0026ndash;action gaps (Sheeran \u0026amp; Webb, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and possible social desirability bias (Bernadi \u0026amp; Nash, 2023). Additionally, Study 1 compared two different message formats, but the design does not isolate which specific features (e.g., colour, wording, layout) influenced the reported intentions, limiting interpretation of the messaging effects. A strength of both studies lies the use of psychological frameworks to underpin the research where the use of two data collection methods encouraged a broader range of patients to engage with the research. The systematic exploration of the barriers and facilitators by applying a behavioural diagnosis, identified which COM-B component(s) to address in the design of an intervention to support this population of inhaler users. Free-text comments captured in Study 1 allowed further explanatory data to be elucidated, while the qualitative nature of Study 2 provided in-depth insights to the barriers and facilitators of inhaler recycling behaviours.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations and further research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo ensure higher uptake, future schemes must be designed in a way that ensures accessibility (e.g. placing recycling bins in convenient locations within the local community). However, public awareness of inhaler recycling remains low. Most existing schemes have been limited to a single setting, typically the pharmacy. A whole-system approach involving all patient-facing healthcare professionals and system-level changes within the broader healthcare environment is likely to be more effective in promoting lasting changes in behaviour. Behavioural insights from both studies were mapped to COM-B and were linked to their respective intervention functions on the BCW. This identified five priority areas which could support the success of future inhaler recycling schemes within community pharmacies.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo establish national-level educational campaigns which highlight the environmental benefits of proper inhaler disposal (Education).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo improve signposting to inhaler recycling schemes in the community, for example, posters in asthma clinics or adding recycling prompts to medication labelling, can help raise awareness and remind inhaler users to engage (Environmental Restructuring).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo support sustained engagement, inhaler users should receive feedback on the environmental impact of recycling schemes (Coercion).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo adopt behaviourally informed messaging to encourage inhaler users to appropriately dispose of inhalers (Persuasion).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo acknowledge (or praise) those who engage in the recycling scheme (Incentivization).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eFuture research should focus on investigating the impact of the above strategies on inhaler recycling uptake, harnessing a mixed-methods approach to identify effective interventions and reasons for their success or otherwise.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTo maximise the impact of inhaler recycling schemes, there is a need to understand what patients currently do with their inhalers once the inhaler cartridge is empty or the inhaler is no longer needed, and to explore their attitudes and beliefs about inhaler disposal. This study highlights significant gaps in awareness and behaviour regarding proper inhaler disposal across two different healthcare contexts. Despite recognising community pharmacies as convenient disposal points, many inhaler users lack knowledge about appropriate disposal methods and often discard inhalers in household waste. While environmental concerns can motivate recycling intentions, forming new, sustained habits remains difficult. The findings underscore the need for multifaceted interventions that address psychological, physical, and social barriers. By leveraging behaviour change frameworks like COM-B and the Behaviour Change Wheel, targeted strategies—such as national education campaigns, improved signposting, feedback mechanisms, persuasive messaging, and incentivization—can enhance engagement with recycling schemes. Importantly, fostering a whole-system approach involving all healthcare professionals can support sustained behaviour change and broaden reach. Future research should focus on implementing and evaluating these interventions to identify effective methods for increasing inhaler recycling uptake. Ultimately, enhancing inhaler disposal practices can contribute to reducing the environmental impact of inhaler use and promote more sustainable healthcare behaviours.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy design and participant recruitment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudy 1: Data were collected using an online quantitative survey (hosted via Qualtrics™ between 09/04/2024 and 28/04/2014) developed to assess inhaler disposal practices, willingness to return inhalers to the pharmacy and the perceived barriers and facilitators to inhaler disposal. Participant recruitment was via a study advert e-mailed to members of the NHS App and NHS Vaccine participant panels.\u003c/p\u003e\u003cp\u003eStudy 2: Barriers and facilitators to returning inhalers to the community pharmacy for recycling. The study was advertised via posters in community pharmacies and social media adverts (X™’, Facebook™) using qualitative methodology. Participants were given a £20 gift voucher.\u003c/p\u003e\u003cp\u003eFor both studies, eligible participants were inhaler users (or their guardian) aged 18 years or older, prescribed one or more MDI inhalers. Convenience sampling was adopted for both studies where participants needed to be living in England for inclusion in study 1 or one of three areas of Wales (North, Southeast and Southwest) for inclusion in study 2.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudy 1: Ethical approval was not required as it met the criteria for service evaluation (Health Research Authority, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) to assess the use and public understanding of NHS recommendations for inhaler disposal, with view to delivering improvements in the quality of guidelines.\u003c/p\u003e\u003cp\u003e Study 2: Cardiff Metropolitan University, Ethics Committee (Reference number: Sta-7736) granted ethical approval, with additional approval granted to combine the datasets of both studies for synthesis and further analysis (Reference number: sta-10739).\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudy 1: A multi-stage quantitative survey (Supplementary Material 1) was designed to gather current inhaler disposal practices and views about inhaler recycling. The opportunity for free-text responses was also provided for some questions. An information sheet and eligibility screening questions were included and informed consent was captured. Eligible participants indicated from a list of options how they currently dispose of their inhalers and reasons for doing so (free text). A multiple-choice question (MCQ) assessed their understanding of NHS inhaler disposal recommendations. Following a between-participant design, half of the respondents were presented with a standard NHS message about inhaler disposal (Message A) and half a behaviourally informed message about inhaler disposal (Message B) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Participants rated their likelihood of returning inhalers in the future on a scale of 1–7. Those scoring 4 or below were presented with specified options to select reasons for not returning inhalers in the future. Awareness of inhalers' environmental impact was assessed by asking participants to estimate how many miles they would need to drive in an average petrol car to have the same carbon footprint of a presented inhaler. Participants made these estimates for both a pressurized metered dose inhaler (MDI) and dry powder inhaler (DPI), where the order of presentation of questions was randomized. Questions regarding the types of inhalers used, guidance received on disposal, perceived importance of reducing inhaler carbon footprint, and support needed for proper future disposal were included. Basic demographic information was also collected.\u003c/p\u003e\u003cp\u003eStudy 2: One-to-one semi-structured interviews were conducted online (via MS Teams™) in Autumn 2023. An interview schedule (Supplementary Material 2) was developed based on existing literature, the COM-B model of behaviour (Michie et al, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and Theoretical Domains Framework (TDF) (Atkins et al, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Caine et al, 2012) as a guiding framework. Introductory questions were used to gain an understanding of inhaler users’ experiences of inhaler recycling and their knowledge of the environmental impact of inappropriate disposal of inhalers. The interviews explored perceptions of the barriers and facilitators to appropriate inhaler disposal and recycling in a community pharmacy. Interviews were audio-recorded, anonymised and transcribed verbatim for analysis (Seage et al, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eStudy 1: All statistical analyses were carried out using RStudio Version 12.0. Descriptive statistics were generated for all recorded variables. One-sample Wilcoxon signed rank tests were used to compare reported estimated carbon footprint mileage equivalents of MDIs and DPIs to their actual mileage equivalents. A Mann-Whitney U test was used to compare likelihood of returning inhalers in the future in response to Message A vs Message B. Likelihood of returning inhalers was further modelled with a binary logistic regression using dichotomized responses, with scores from 1 to 6 on the likelihood scale coded as 0 and a score of 7 coded as 1. Robustness checks were conducted using ordinal logistic regressions.\u003c/p\u003e\u003cp\u003eStudy 2: As reported in Seage et al, (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), framework analysis was undertaken by mapping the interview data to the COM-B model and thematic analysis of any data that was not mapped to the COM-B (Pope, Ziebland \u0026amp; Mays, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Pope \u0026amp; Mays, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Braun \u0026amp; Clark, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Codes were applied to the framework’s pre-existing categorical themes (e.g., physical capability, psychological capability, etc.).\u003c/p\u003e\u003cp\u003eData from study 1 and study 2 were synthesised by mapping key findings to the COM-B components. The Behaviour Change Wheel was used to make recommendations for intervention functions that would support future behaviour change.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you to Sian Evans and Dr Angharad Wooldridge at Public Health Wales for providing oversight of Study 2 and helping with inhaler user recruitment from community pharmacies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTMcE, TH and AB contributed to the design, conduct and data analysis for Study 1. DHJ, CHS, SB, AC and AH contributed to the design, conduct and data analysis for Study 2. DHJ, TMcE, CHS and TH synthesised the data from Studies 1 and 2 and drafted the manuscript with input from HT. All authors provided critical review of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding to conduct the quantitative study (Study 1). Funding was received from Public Health Wales to conduct the qualitative study (Study 2). No further funding was received to conduct the merger of findings of both studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eADDITIONAL INFORMATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary information. The online version contains supplementary information available at\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAtkins, L., Francis, J., Islam, R. et al. (2017). 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PMID: 32724806; PMCID: PMC7364235.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalpole S, Fitzpatric A, Moffatt K, Smith K, Potts A, Doe S, Burns G, Tedd H (2021) P187 Ease of use, effectiveness and environmental impacts: Evaluating inhaler prescriptions, patient preferences and opportunities for improvement. \u003cem\u003eThorax\u003c/em\u003e 2021;76:A190-A191.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilkinson AJK, Braggins R, Steinbach I, \u003cem\u003eet al (\u003c/em\u003e2019) Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England \u003cem\u003eBMJ Open\u003c/em\u003e 2019;9:e028763. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2018-028763\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2018-028763\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"npj-primary-care-respiratory-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"npjpcrm","sideBox":"Learn more about [npj Primary Care Respiratory Medicine](https://www.nature.com/npjpcrm/)","snPcode":"41533","submissionUrl":"https://submission.springernature.com/new-submission/41533/3","title":"npj Primary Care Respiratory Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"NPJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7179716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7179716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe National Health Service (NHS) aims to reduce emissions from inhalers, a major contributor to its carbon footprint. Despite willingness, patient awareness and engagement with appropriate inhaler disposal and recycling remains low. This paper combines two studies both using behavioural frameworks with different methodological approaches to explore inhaler disposal behaviours, and barriers and facilitators to recycling uptake. Synthesis of two datasets from quantitative (Study 1) and qualitative (Study 2) studies was undertaken, and deductive analysis was conducted, based on the COM-B (Capability, Opportunity, Motivation) model of behaviour. Findings were mapped to the Behaviour Change Wheel (BCW) to provide recommendations for improving disposal practices. Inhaler users were unaware of the need to return inhalers to pharmacies for disposal and often discarded them in domestic waste. Inhaler users viewed community pharmacies as convenient locations for recycling schemes due to their proximity to the local pharmacy. However, they were unlikely to engage with initiatives that require significant additional effort such as traveling out of their way to return to the inhaler. Although awareness of environmental impacts can motivate intentions to recycle, users often struggle to develop and maintain consistent recycling habits. This highlights the complexity of behaviour change, requiring interventions that address psychological, physical, and social barriers. By applying behaviour change frameworks such as COM-B and the BCW, targeted strategies can be designed to enhance inhaler recycling. These include national educational campaigns to raise awareness, better signposting and prompts in healthcare settings, providing feedback on environmental benefits, persuasive messaging linking disposal to carbon reduction, and incentivization to encourage participation. A whole-system approach, engaging all healthcare professionals, is critical for sustained behaviour change and broader reach. Future research should focus on implementing and evaluating these interventions to identify the most effective methods for improving inhaler disposal/recycling and reducing the environmental impact of inhaler use.\u003c/p\u003e","manuscriptTitle":"Patient Attitudes, Beliefs, and Practices in Environmentally Friendly Inhaler Disposal: A Mixed-Methods Evaluation with Behaviourally Informed Recommendations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 10:19:54","doi":"10.21203/rs.3.rs-7179716/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-01T14:26:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-21T07:51:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29037768687992471200919683848088517125","date":"2025-11-19T21:20:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250421821629314931422507738963204943061","date":"2025-11-11T00:26:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-24T11:24:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202724216984433126511160212366055119707","date":"2025-10-07T21:17:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32681714848004518271214465567362726514","date":"2025-10-06T13:19:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T06:58:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74405170592027747862955525344572163116","date":"2025-09-11T09:37:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-30T06:55:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-24T00:16:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T00:15:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"npj Primary Care Respiratory Medicine","date":"2025-07-21T16:51:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"npj-primary-care-respiratory-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"npjpcrm","sideBox":"Learn more about [npj Primary Care Respiratory Medicine](https://www.nature.com/npjpcrm/)","snPcode":"41533","submissionUrl":"https://submission.springernature.com/new-submission/41533/3","title":"npj Primary Care Respiratory Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"NPJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf781739-b196-4e42-a02b-824f1b0cda45","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":52445469,"name":"Earth and environmental sciences/Environmental sciences"},{"id":52445470,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2026-04-30T06:40:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 10:19:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7179716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7179716","identity":"rs-7179716","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}