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SP6 Oral liquid medicine contribution to the carbon footprint of healthcare system: scoping review
  1. Steve Tomlin1,
  2. Amin Houshian2
  1. 1Great Ormond Street Hospital for Children
  2. 2King’s College Hospital, London


Aim Medicines account for 25% of NHS England’s carbon footprint.1 By exploring a carbon footprint breakdown of oral liquid medicines (OLMs), their contribution to the carbon footprint of healthcare systems can be described. Carbon-intensive aspects can be highlighted, and recommendations can be hypothesised to achieve a more sustainable pharmaceutical supply chain. This scoping review aimed to explore what constitutes the carbon footprint of OLMs and the extent of their contribution to the carbon footprint of healthcare systems.

Method A systematic search of studies published in English language was conducted on EMBASE, PubMed, Scopus, and grey literatures. Data screening and extraction were performed independently by two reviewers. The quality of included studies was assessed using modified-NIH (National Institute of Health) and modified-AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) quality assessment tools.2, 3 The review was conducted in accordance with the PRISMA guidelines for systematic reviews.4

Results In total, 65 articles were identified for full text review. None of them fully met the inclusion criteria, however 20% (13/65) of them provided data for our outcomes of interest: those reporting on the contribution of pharmaceuticals and chemicals to healthcare’s carbon footprint (n=5); those reporting on the pharmaceutical waste by dosage form and packaging (n=4); and those described the causes of pharmaceutical waste and potential waste-minimising recommendations (n=4). Evidence showed that the contribution of pharmaceuticals and chemicals to the greenhouse gas emissions of the NHS in England was reported to have decreased by 26%, while anaesthetic gases and metred-dose inhaler emissions decreased by 75%, between 1990 and 2019. Wasted OLMs were largely associated with medicine non-adherence and inappropriate dosing frequencies. Medicines packaged as liquids were found to be the most wasted due to packaging size, inappropriate prescribing, and inadequate disposal procedures. Prescriptions that were no longer required and inadequate storage were found to be the main reasons reported for accumulating medicines.

Conclusions This review showed that there was no doubt that medicines and chemicals have had a substantial impact on the carbon footprint of healthcare systems over the past three decades, although no definitive conclusion could be made on the contribution of OLMs. However, OLMs were found to have a higher wastage and non-adherence compared to oral solid medicines. We know that unused and wasted medicines cause unwarranted pressure on the environment and carbon footprint and thus these two aspects need to be reduced.

Further research on the sustainability and carbon footprint of all medicines including OLMs in health care systems is warranted. The implementation of end-to-end traceability and an absolute record of carbon emission data across the life cycle of medicines might enable identifying the root cause of carbon-intensive dosage forms.


  1. Greener NHS. Areas of focus. Available from:

  2. National Institute of Health (NIH) – National Heart, Lung, and Blood Institute. Study Quality Assessment Tools. Available from:

  3. Landford T. University of Canberra Library. Grey Literature in Health: Critical Appraisal, AACODS Checklist. Available from:

  4. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71.

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