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measure in the exhaled breath&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Starting from June 2020 it was possible&#44; keeping the distance between patients and the use of personal protection devices&#44; to resume the activity of the antismoking center&#44; but the Covid-19 situation has posed non-emergency labs with the question of how to proceed with clinical tests safely while avoiding virus transmission among patients<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#59; so&#44; we addressed the problem of safe CO measurement&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The level of carboxyhemoglobin in the blood can be determined by measuring the exhaled CO through an instrument that provides the CO value in parts per million &#40;ppm&#41;&#46; This type of measurement is then configured as an extremely useful tool in smoking cessation assessment&#44; to enhance motivation to quit and for follow-up of smoking cessation programs&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">One of the major company for CO analyzers is Bedfont Scientific Ltd with its main product &#8220;Smokerlyzer&#8482;&#8221;&#44; a portable instrument with research and education aims&#46; The model we have available in our antismoking centre is a Micro<span class="elsevierStyleSup">&#43;</span> Smokerlyzer&#8482; model purchased in 2012&#46; It is composed of the electronic device &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#44; the fitting provided with an antibacterial filter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41; which lasts 30 days and the disposable mouthpieces &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46; For the latest models Bedfont has produced disposable antibacterial filters&#44; but our model is not compatible&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">To safely use the CO analyzer&#44; we thought of substituting the fitting with an antibacterial filter with a new one&#44; specially created &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>d&#41;&#46; This fitting&#44; designed with the help of our clinical engineering department&#44; was made of a plastic polymer and printed via a 3D printer&#46; The size of the fitting &#40;section and length&#41; was calculated to make minimum modifications in order not to change significantly the flow rate and the volume of air entering the device&#59; in this way it is possible to avoid alterations related to the detection and calibration of the instrument&#46; It does not contain any filters and it can be washed and disinfected after each use&#46; The fitting has been molded to allow the attachment of disposable mouthpieces that we usually use for the execution of spirometries &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>e&#41;&#46; This mouthpiece contains an electrostatic and certified mechanical filter that removes bacteria and viruses at an efficiency rate of &#62;99&#37;&#44; thus reducing risks of cross contamination during testing&#46; Through this solution we can guarantee the use of a single filter for each patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The safety of this measurement must be guaranteed not only for patients but also healthcare professionals&#46; The use of appropriate personal protective equipment &#40;PPE&#41; is of pivotal importance for the healthcare workers involved in the care of patients with viral infections&#44; such as the current pandemic&#44; Covid-19&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In collaboration with Health and Safety Protection Unit&#44; considering that this procedure provides for the emission of exhaled breath&#44; we have reviewed it&#58; workers must carry out the procedure with Covid-19 personal PPE and&#44; as further precaution&#44; the patient is asked to plug his or her nose with disposable forceps so that there is no exhalation from the nasal cavities during the procedure&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the risk of Covid-19 transmission&#44; it was impossible for us to test the CO analyzer for correct measurement of exhaled CO for smokers with and without modified fitting&#44; but during the first period of the modified device use&#44; we verified that the detector has not undergone alterations in the measurement of the CO concentration&#46; In fact&#44; we used the device during our checks among smoking patients and we detected values &#8203;&#8203;compatible with the self-reported smoking status&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The completely new situation that arose during the period of the Covid-19 pandemic&#44; characterized by social isolation&#44; physical distancing&#44; possible loss of employment and prolonged lockdown&#44; is highly stressful and therefore predisposing people to find refuge in addictive substance&#44; and among these&#44; tobacco&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Therefore&#44; smokers and ex-smokers are at greater risk of worsening their health condition by smoke dependence due to the pandemic&#59; furthermore&#44; smoking does not only constitute individual damage&#58; the lockdown has forced many people to stay at home&#44; increasing indoor smoking and therefore the possibility of exposing family and neighbors to secondhand smoke<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; in addition&#44; cigarette smoke has been identified as a possible vehicle for the Covid-19 virus as droplets are more easily released into the environment while smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In addition some studies<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> have even indicated that the pandemic has increased the possibility of people wanting to quit smoking&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All these considerations suggest the importance of promoting smoking cessation during the Covid-19 pandemic&#46; In the future it will be necessary not to interrupt the antismoking services&#44; including the measurement of CO safe for patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no Conflicts of interest to declare&#46;</p></span></span>"
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Letter to the Editor
COVID-19 does not stop good practice in smoking cessation: Safe use of CO analyzer for smokers in the Covid era
E. Munarinia, C. Veronesea,
Corresponding author
chiara.veronese@istitutotumori.mi.it

Corresponding author at: Pulmonology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
, A.C. Ogliaria, F. Allegria, M.G. Bolchib, R. Boffia
a Antismoking Center, Pulmonology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy
b Health & Safety Protection Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy
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measure in the exhaled breath&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Starting from June 2020 it was possible&#44; keeping the distance between patients and the use of personal protection devices&#44; to resume the activity of the antismoking center&#44; but the Covid-19 situation has posed non-emergency labs with the question of how to proceed with clinical tests safely while avoiding virus transmission among patients<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#59; so&#44; we addressed the problem of safe CO measurement&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The level of carboxyhemoglobin in the blood can be determined by measuring the exhaled CO through an instrument that provides the CO value in parts per million &#40;ppm&#41;&#46; This type of measurement is then configured as an extremely useful tool in smoking cessation assessment&#44; to enhance motivation to quit and for follow-up of smoking cessation programs&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">One of the major company for CO analyzers is Bedfont Scientific Ltd with its main product &#8220;Smokerlyzer&#8482;&#8221;&#44; a portable instrument with research and education aims&#46; The model we have available in our antismoking centre is a Micro<span class="elsevierStyleSup">&#43;</span> Smokerlyzer&#8482; model purchased in 2012&#46; It is composed of the electronic device &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#44; the fitting provided with an antibacterial filter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41; which lasts 30 days and the disposable mouthpieces &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46; For the latest models Bedfont has produced disposable antibacterial filters&#44; but our model is not compatible&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">To safely use the CO analyzer&#44; we thought of substituting the fitting with an antibacterial filter with a new one&#44; specially created &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>d&#41;&#46; This fitting&#44; designed with the help of our clinical engineering department&#44; was made of a plastic polymer and printed via a 3D printer&#46; The size of the fitting &#40;section and length&#41; was calculated to make minimum modifications in order not to change significantly the flow rate and the volume of air entering the device&#59; in this way it is possible to avoid alterations related to the detection and calibration of the instrument&#46; It does not contain any filters and it can be washed and disinfected after each use&#46; The fitting has been molded to allow the attachment of disposable mouthpieces that we usually use for the execution of spirometries &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>e&#41;&#46; This mouthpiece contains an electrostatic and certified mechanical filter that removes bacteria and viruses at an efficiency rate of &#62;99&#37;&#44; thus reducing risks of cross contamination during testing&#46; Through this solution we can guarantee the use of a single filter for each patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The safety of this measurement must be guaranteed not only for patients but also healthcare professionals&#46; The use of appropriate personal protective equipment &#40;PPE&#41; is of pivotal importance for the healthcare workers involved in the care of patients with viral infections&#44; such as the current pandemic&#44; Covid-19&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In collaboration with Health and Safety Protection Unit&#44; considering that this procedure provides for the emission of exhaled breath&#44; we have reviewed it&#58; workers must carry out the procedure with Covid-19 personal PPE and&#44; as further precaution&#44; the patient is asked to plug his or her nose with disposable forceps so that there is no exhalation from the nasal cavities during the procedure&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the risk of Covid-19 transmission&#44; it was impossible for us to test the CO analyzer for correct measurement of exhaled CO for smokers with and without modified fitting&#44; but during the first period of the modified device use&#44; we verified that the detector has not undergone alterations in the measurement of the CO concentration&#46; In fact&#44; we used the device during our checks among smoking patients and we detected values &#8203;&#8203;compatible with the self-reported smoking status&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The completely new situation that arose during the period of the Covid-19 pandemic&#44; characterized by social isolation&#44; physical distancing&#44; possible loss of employment and prolonged lockdown&#44; is highly stressful and therefore predisposing people to find refuge in addictive substance&#44; and among these&#44; tobacco&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Therefore&#44; smokers and ex-smokers are at greater risk of worsening their health condition by smoke dependence due to the pandemic&#59; furthermore&#44; smoking does not only constitute individual damage&#58; the lockdown has forced many people to stay at home&#44; increasing indoor smoking and therefore the possibility of exposing family and neighbors to secondhand smoke<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; in addition&#44; cigarette smoke has been identified as a possible vehicle for the Covid-19 virus as droplets are more easily released into the environment while smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In addition some studies<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> have even indicated that the pandemic has increased the possibility of people wanting to quit smoking&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All these considerations suggest the importance of promoting smoking cessation during the Covid-19 pandemic&#46; In the future it will be necessary not to interrupt the antismoking services&#44; including the measurement of CO safe for patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no Conflicts of interest to declare&#46;</p></span></span>"
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Pulmonology

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