The Skinny on Marit Bjoergen’s Inhaler

Chelsea LittleMay 16, 201114
Bjoergen (1) and Kowalczyk (5) cross the line in the classic sprint at the Vancouver Olympics.

At Polish three time overall World Cup champion Justyna Kowalczyk has never been one to keep her mouth shut. Take, for example, her accusation that Marit Bjoergen’s asthma medicine is performance-enhancing.

“Without the medicine Marit would not have won gold medals,” Kowalczyk said at the 2010 Olympics in Vancouver.

If Bjoergen has asthma, then it may very well be true. But Kowalczyk’s implication was that either Bjoergen did not have asthma and was taking the drugs anyway, or that the inhaler was so beneficial that it more than compensated for the Norwegian star’s medical condition.

Since Kowalczyk’s assertion has been much discussed, FasterSkier decided to investigate salbutamol, the inhaled medicine which Bjoergen reportedly uses. Based on scientific studies from around the world, we wanted to answer the following question: should Kowalczyk shut up, or speak up?

Asthma, Athletes, Salbutamol, and WADA

Asthma is a chronic lung condition characterized by two things: constriction of the smooth muscle in the airways, and inflammation of those same airways. This causes the airways to narrow, making it more difficult to breathe. Symptoms of asthma include coughing, wheezing, chest tightness, and shortness of breath. Asthma can be caused by a variety of symptoms including exercise, allergies, and air pollution.

It has been widely reported that elite athletes, particularly in endurance sports, have a high incidence of asthma compared to the general population. To fans, it might seem fishy that so many skiers have been diagnosed with asthma – but it also might be true. (note: FasterSkier will cover this issue separately in a subsequent article.)

Numbers vary by study and by country, but some surveys report that as many as 50 percent of elite athletes have asthma-like symptoms. At the Vancouver Olympics, 7.1 percent of athletes across all disciplines had documented asthma or airway hyperresponsiveness, and this group won 11.8 percent of the medals.

Salbutamol, which is called albuterol in the U.S., is a short-acting β2-agonist, a class of drugs used to treat asthma. It’s prescribed not only to athletes, but is also one of the most commonly-used inhalers in the U.S. In clinical trials, one brand of salbutamol inhaler was shown to increase lung function in asthmatics in as little as six minutes.

Salbutamol is not a steroid. β2-agonists act on the β2-andrenergic receptor, which works with several proteins and is associated with calcium channels. Inhaling salbutamol relaxes smooth muscle in the bronchi of the lungs, which leads to a dilation of the airways. In this way, it combats the constrictions brought about by exercise-induced asthma.

A 1992 study led by Alan Morton at the University of Western Australia and published in the Clinical Journal of Sport Medicine noted in its introduction that banning salbutamol outright “would virtually eliminate asthmatics from competition.”

Starting in 2009, WADA required a Therapeutic Use Exemption (TUE) for any athletes who used salbutamol. To get a TUE, athletes not only had to report asthma-like symptoms, but they also had go through a Bronchial Provocation Test, which would bring about the symptoms in a doctor’s office so that they could be documented.

In 2010, WADA changed its tune. While other β2-agonists such as formoterol and terbutaline remained on the prohibited list, salbutamol was only prohibited at urine concentrations greater than 1,000 mg/mL, which was higher than possible when taking a normal inhaled dose. In order to inhale enough of the drug to pass the urine limit, an individual would be at risk of developing tolerance, which would negate any benefit they might be getting.

The limit instead might have been designed with oral consumption of salbutamol in mind. That method of administering the drug leads to other effects, like increasing muscle mass and quickening the metabolism of lipids and carbohydrates. Oral salbutamol can also act as an antidepressant.

Regardless, athletes no longer needed a TUE to inhale salbutamol, and instead were simply required to list it on the Doping Control Form whenever they were tested.

While WADA did not explain its reasoning in changing the status of salbutamol, two basic factors were probably at play: first, the extremely high prevalence of salbutamol prescriptions in athletes who actually had asthma, and second, the lack of overwhelming evidence that salbutamol enhanced performance in those who didn’t.

General Consensus of Studies

Since use of salbutamol in asthmatic athletes merely levels the playing field, the real question about WADA’s control of the drug is whether it has any benefits for non-asthmatic athletes.

After thorough research, FasterSkier found fifteen studies and three reviws examining the effects of inhaled salbutamol on nonasthmatics. While each study is different, the fifteen trials had several things in common:

  • Almost all of them use only high-level athletes, often cyclists, runners, skiers, or triathletes.
  • They are crossover studies: each treatment is used on each athlete, giving the test subject salbutamol one day and a placebo another, and then comparing performance for each athlete individually.
  • They are double-blind: the researcher administering the test – which is usually on a treadmill or stationary bicycle – has no idea which of the treatments the athlete has received.

The vast majority of these studies use only male subjects, probably due to the fact that there are many more elite male athletes than females and therefore the pool of female test subjects is limited.

Of the fifteen studies, twelve found no enhancement of performance parameters after taking salbutamol, while three found some benefit in one or more measures of performance or lung function.

The Consensus Is: Why Bother?

While the twelve studies which found no benefit for nonasthmatic athletes using the drug had some things in common, they were all constructed slightly differently. Some tests were shorter, some longer; some measured VO2Max and others the amount of time to complete a given distance; and some even found that salbutamol had negative effects on performance.

The Studies – No positive performance impact of salbutamol

Carlsen KH, et al. The effect of inhaled salbutamol and salmeterol on lung function and endurance performance in healthy well-trained athletes. Scand J Med Sci Sports 1997: 7: 160–165. (link)

Fleck S, et al. Effects of acute inhalation of albuterol on submaximal and maximal VO2 and blood lactate. Int J Sports Med 1993;14:239—43. (link)

Goubault C, et al. Effects of inhaled salbutamol ingestion in exercising non-asthmatic athletes. Thorax 2001;56:675—9. (link)

Heir T, Stemshaus H. Salbutamol and high-intensity treadmill running in non-asthmatic highly conditioned athletes. Scand J Med Sci Sports 1995;5:231—6. (link)

Lemmer J, et al. The effects of albuterol on power output in nonasthmatic athletes. Int J Sports Med 1995;16:243—9. (link)

McKenzie S, et al. Salbutamol and treadmill performance in non-atopic athletes. Med Sci Sports Exerc 1983;15:520—2. (link)

Meeuwisse W, et al. The effect of salbutamol on performance in elite nonasthmatic athletes. Med Sci Sports Exerc 1992;24:1161—6. (link)

Morton AR, et al. Is salbutamol ergogenic? The effects of salbutamol on physical performance in high-performance nonasthmatic athletes. Clin J Sports Med 1992;2:93–7. (link)

Morton AR, et al. Changes in anaerobic power and stength performance after inhalation of salbutamol in non asthmatic athletes. Clin J Sport Med 1993;3:14–19. (link)

Norris SR, et al. The effect of salbutamol on performance in endurance cyclists. Eur J Appl Physiol 1996;73:364–8. (link)

Sandsund M, et al. Effect of cold exposure (-15 degrees C) and salbutamol treatment on physical performance in elite nonasthmatic cross-country skiers. Eur J Appl Physiol Occup Physiol 1998: 77: 297–304. (link)

Sporer B, et al. Dose response of inhaled salbutamol on exercise performance and urine concentrations. Med Sci Sports Exerc 2008;40:149—57. (link)

Many of the researchers found an immediate, quick increase in lung function just after taking the inhalation. However, they found that the benefit did not last when the athlete began exercising, and by the time the test was over, the numbers were back to normal. So while they did not always claim that salbutamol had no effect, they could claim that it had no apparent effect on performance.

One example of this was a study was led by Dr. Mariann Sandsund, a scientists at the Norwegian research organization SINTEF. Sandsund’s 1997 study specifically tested the effect of salbutamol on nonasthmatic cross-country skiers at cold temperatures.

Sandsund had the skiers run on a treadmill in a climate-controlled room at -15 degrees Celsius. She measured oxygen uptake, heart rate, blood lactate concentration, and time to exhaustion during the test, which was done twice for each athlete – once ten minutes after inhaling a placebo, and once ten minutes after inhaling a dose of salbutamol.

The men warmed up at 55 percent of their VO2Max for ten minutes, and then ran for ten minutes at 95 percent of VO2Max and five minutes at 85 percent of VO2Max. This was designed to bring on bronchoconstriction if possible. Finally, they did a “step test”, in which the treadmill speed was increased incrementally until the athletes could no longer keep up.

Sandsund and her colleagues found that forced expiratory volume, or how much air the men were breathing out, increased ten minutes after they inhaled salbutamol. However, once they started exercising, the difference between salbutamol and the placebo disappeared. Neither lung function, heart rate, lactate levels, nor time to exhaustion were affected by the salbutamol during the workout.

A group of French researchers working with triathletes found results which went even further in disproving the benefits of the drug: with a “supratherapeutic”, or higher-than-prescribed, dose of salbutamol, average endurance time at 85 percent VO2Max decreased from over 23 minutes down to exactly 21 minutes. In other words, the athletes became too exhausted to continue cycling more than two minutes earlier when they took a high dose of the drug.

“The bronchodilation induced by salbutamol was modest in magnitude, being significant only at the beginning of exercise,” the researchers wrote. “Inhaled salbutamol has little effect on systemic parameters.”

The study, led by Francis Christian Goubault, was more extensive than most of the others. It also examined whether the inhaling salbutamol had any of the same benefits as ingesting it orally. The answer was no: the athletes had the same level of muscle fatigue, alertness, and calmness whether they inhaled the placebo or the real drug, and their mood was more or less identical. They also failed to find any differences in blood concentrations of glucose, lactate, glycerol, or fatty acids.

In a more general study on β2-agonists, Kai-Håkon Carlsen’s research group at the Norwegian University for Sports and Physical Education wrote that “… in the present study, we found no improvement brought about by inhalation of salbutamol or salmeterol for any parameter of endurance performance in healthy well-trained male athletes, even if we employed a higher than usual dose of inhaled salbutamol… this finding… discourages rather than encourages the use of these inhaled b2-agonists in healthy competitive athletes.”

A Few Cases Of Enhanced Performance

A group of scientists in the Netherlands found the most recent evidence of sulbutamol aiding performance in non-asthmatic athletes. The other two cases were in a 1988 study by a trio of researchers at the University of California, Berkeley, and a 1992 effort from the University of Miami.

The Netherlands study, which was led by Dr. Marleen van Baak, was published in 2004. Van Baak used sixteen male cyclists and triathletes for her test subjects, and the testing was done on a stationary bicycle. The test was to time trial a distance that would theoretically take one hour to complete at 75 percent of max power.

Each athlete did the test twice: once after inhaling 800 mg of salbutamol – a level higher than the recommended therapeutic does – and once after inhaling a placebo. In each case, the average time to complete the workout was over an hour. But Van Baak and her colleagues found that it took the athletes an average of 83 seconds less to finish the time trial when they had taken salbutamol.

Looking at the data, there were two subjects who took much longer to complete the time trial without salbutamol than with the drug, and their results pulled the data toward statistical significance. One of them was also the slowest athlete in the group. For the faster, better conditioned athletes, the times for the two tests were more similar.

The Studies – Salbutamol aiding performance

Bedi J, et al. Enhancement of exercise performance with inhaled Can J Sport Sci 1988;13: 144—8. (link)

Signorile J, et al. Effect of acute inhalation of the bronchodilatator, albuterol, on power output. Med Sci Sports Exerc 1992;24:638—42. (link)

Van Baak M, et al. Inhaled salbutamol and endurance cycling performance in non-asthmatic athletes. Int J Sports Med 2004;25:533—8. (link)

Why did van Baak and her colleagues find a difference where others had not?

“The reason that we did see an effect in our study, in contrast to for instance Goubault et al [the French researchers], who also studied inhalation of 800 mg salbutamol, may be that we used a different protocol to measure endurance performance in highly trained athletes,” they wrote in the International Journal of Sports Medicine.

“This protocol has been shown to be more reproducible than a time to exhaustion test in trained athletes and therefore may allow to pick up smaller differences in performance… From the plasma lactate curves it appears that at the end of this type of trial subjects perform a ‘finishing kick’, which is absent during a time to exhaustion test.”

Van Baak’s explanation is that in a test where athletes run or cycle until they can no longer continue, there is not such a dramatic shift to the anaerobic system. In an actual race, or a fixed-distance or fixed-time time trial, there is real incentive to sprint at the end.

Despite the several physiological parameters measured by the Dutch team, they could not discover why the athletes performed better with salbutamol than they did with the placebo.


Are van Baak and her colleagues right? It’s hard to say. Athletes who have done VO2Max tests before can tell you that a “step test” and a fixed-time or fixed-distance test are certainly different. However, of the twelve studies which found no benefit to salbutamol use, there were a variety of test formats, and finishing an exhaustion test often does consist of more or less sprinting to avoid dropping off the back of the treadmill. Van Baak may have a point, but she also might be oversimplifying.

None of these test formats were exactly identical to an actual ski race, because all of the researchers were interested in understanding the underlying mechanisms of any differences they might find. They wanted to measure lactate, VO2Max, and other variables that might show how salbutamol worked. To do that, they had to work in a laboratory.

Until someone finds a way to study the effects of salbutamol on the trails, these studies will be the best tool we have for understanding whether the medication confers any benefits on non-asthmatic athletes. And despite the findings of van Baak and her colleagues – which suggest that more work should be done – the consensus seems to be that salbutamol doesn’t enhance performance.

Given the information they have to work with, WADA has probably made the right decision, and the significant number of skiers who suffer from asthma can breathe easy – without a TUE.


Chelsea Little

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  • ajohnson

    May 16, 2011 at 3:54 pm

    Nice article…still won’t quite any angry comments from “Justyna’s Fan” on There is no point to rational discussion with those who are emotionally convinced that they are right. I was wondering if you could do some more digging. I read that Marit received special dispensation from WADA and FIS to use symbicort in addition to salbutamol. Is this a reporting error? Symbicort is an inhaled corticosteroid, and much of the anger among Justyna’s fan club seems to stem from this. Either way, I have done a Pubmed search and cannot find any conclusive evidence that inhaled corticosteroids have any performing enhancing effect on elite athletes. On the contrary, I think the side effects of inhaled corticosteroids (even minor ones like insomnia and feeling jittery) out-shout any benefit…unless you really need it! Marit’s outspoken opponents are essentially implying that Marit does not have asthma and her physicians are corrupt (or incompetent) and her medical record (which the media does not and should not have access to) is falsified. That smells like conspiry theory.

  • Sandrine

    May 16, 2011 at 4:08 pm

    Thank you for all that digging. Like ajohnson, I am not sure it will convince the conspiracy theorists to let it rest, which is why I’ll probably keep avoiding the FIS boards next season – trying to make my way through all the trash some overzealous Justyn (and Marit) fans post over there is just too much work :p

    But to be honest a little part of me had been uneasy about the whole thing when it surfaced last year and following conflicting information journalists gave in the wake of Justyna’s declarations (which begged several questions, including why, if salbutamol doesn’t enhance performance of athletes who do not suffer from asthma, why would WADA essentially ban it except under specific circumstances?) : your article did answer, or at least confirm my understanding of, several questions I had about the subject, and for that, I am thankful!

  • Tim Kelley

    May 16, 2011 at 8:33 pm

    This article delves into the minutia and details of this issue, and arrives at no verifiable conclusion. This article tries to pinpoint physical evidence when in fact the argument, and the controversy, is philosophical.

    If you take this issue to the 10,000 foot level and look down it is much more in focus. Athletes enter their respective sports with their own genetic limitations. If these genetic limitations are compensated by use of drugs, then that is cheating. If a guy’s genetics make him too small for football, and he takes steroids to get big, that’s cheating. If a girl is born with lungs that can’t take the rigors of winter endurance sports, and she takes drugs to get around this genetic limitation, that too is cheating.

    There is little sense in debating the organic chemistry of this inhaler drug issue. That’s just mental masturbation. Keep the big picture in focus. The key is that if an athlete’s genetic limitations are bypassed by using a drug, such as those dispensed by asthma inhalers, then that is cheating.

  • anima

    May 16, 2011 at 9:11 pm

    Tim, you have taken this past the 10,000 ft level. You are out in outer space. The final frontier.
    Haven’t you ever seen the movie “Rudy”?

  • ajohnson

    May 16, 2011 at 10:33 pm

    Seriously Tim?! If I was Kris Freeman I would be outraged at that kind of short-sightedness. Insulin is also on the prohibited list requiring special dispensation for use. So because of Kris’ genetics do you think he should be playing ping-pong? Come on. Or do you think that diabetes is a legitimate disease but asthma is not?
    -Adam Johnson

  • hbxcskier

    May 16, 2011 at 10:59 pm

    I’ll simplify it further. Someone is born with poor eyesight. Is it cheating if he/she is allowed to use glasses/contacts?

    Thanks for the insightful article perhaps it will quell some of the Marit hate on

  • ajohnson

    May 17, 2011 at 12:00 am

    I hope it would quell the anti-Marit (and even anti-Norwegian) comments, but it won’t. Norwegian media sources have quoted Marit admitting that she uses symbicort, not just salbutamol. That is largely why there are so many angry comments. Nice article but it only addresses one of the so-called “villains in the drama” (referring to medications not athletes).

  • Almdudler

    May 17, 2011 at 1:31 am

    Well put hbxcskier. I hope no one would accuse Tim Burke of cheating because he had surgery to correct compartment syndrome.

  • Mike Trecker

    May 17, 2011 at 9:47 am

    I remember standing on the sidelines of an eyeglasses debate at a team house in Lake Placid around ’89 or ’90. That debate will go on forever without resolve. My opinion is that sports is a big game, and personally, I would rather have more people in the game than less. Sports and games’ importance is to “have fun” not to crown “the best” so that we can laud the winners with grand proclamations of how “great” they are. The game is important, the actual results?….less so. As far as the petty fight between two accused dopers who crush all competition….not a fan of either. Looking forward to Johaug or Randall slapping them both around.

  • Mike Trecker

    May 17, 2011 at 9:49 am

    Oh yeah, I forgot, thanks FS for this excellent read.

  • Rdgoes

    May 17, 2011 at 1:03 pm

    The thought that Bjoergen’s dominance is due to any of the medications she is taking is crazy. You don’t get that much better than you competition by using an inhaler when its cold out. You reach that level by training more and training harder than your competition. The use of an inhaler just allows Bjorgen to participate without the fear of having an asthma attack. The last thing you want to be worried about at the start of a world championship race is , “Gee I hope my throat doesn’t close up at 5k…” I feel it is very presumptuous for anyone to give her hard time who doesn’t
    A) Have asthma that requires an inhaler to control
    B) Trains as much and as hard as she does.

  • Lars

    May 18, 2011 at 11:51 pm

    Tim Kelley Bjørgens asthma is not genetic its is caused by prolonged heavy activity in cold climates so it is not something she is born with.
    Second Messi arguably the worlds best footballer was threated with growth hormones when he was growing up so your exampel is really bad. And if your talking about the American version of football then well id be surprised if most of those athletes arent on some kind of substance that would be considered doping by wada.

  • davidf2d

    May 21, 2011 at 1:14 pm

    A really well written article. Translating science-speak into something for everyone to read is a really tough task! The only reference I ever found for Marit using Symbicort is from a rather sketchy looking site called NorwegianNews in English (or something like that). If that’s the only source, I’d be inclined to put it down to bad reporting and ignore it.
    The main thing to remember in all this is that WADA couldn’t give a rat’s *** about Marit or Justyna. They want to regulate the use of performance enhancing drugs in ALL sports. They also have a lot of resources, financial and scientific to sort through all this conflicting information. I seriously doubt that if WADA approves salbutamol under a TUE or some other rule that it would still be performance enhancing.

  • willygraves

    May 29, 2011 at 7:06 pm

    Everybody was cheating on the BPT anyways. All you have to do is breath softer into the spirometer after the baseline, and the Ventolin is yours. This isn’t rocket science.

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