REVIEW
Health effects of air pollution in
Canada: Expert panel findings for
The Canadian Smog Advisory
Program
DAVID M STIEB*t MD MSc CCFP FRCPC, L DAVID PENGELLYt+ PhD, N INA ARRON * BScPHN MHA,
S MARTIN T AYLORt§ PhD, MARK E RAIZEN NE* BSc
*A ir Quality Health Effects Research Section, Health Canada, Ottawa, tJnstitute of
Environment and Health. McMaster University and University of Toronto, +Departments of
Medicine and Engineering Physics, McMaster University, Hamilton, §Department of
Geography, McMaster University, Hamilton. Ontario
OM STIEU, LO PE GELLY, N ARRON , SM TAYLOR, ME
R AIZF.N E. Health effects of air pollution in Canada:
Expert panel findings for The Canadian Smog Advisory
Program. Can Res pir J 1995;2(3): 155-1 60.
O n.J ECTIVE: To revit:w the evidrnce on health effects of air
pollution for the Canadian Smog Advisory Program.
METHODS : Evide nce w;1s reviewed by two expert pane ls.
who were asked to define the health effects expected at
levels o f ex posure given by the National Ambient Air Quality O bjecti ves. to examine a variety or issue., re lated to
communicating with the public about environmental health
risks. and to draft health messages for the advisory program.
R ESU LTS : The panel s concluded that health effects or
gro und-level 01011..: at k'vcls that occur in Canada include
pulmonary inflammation. pu lmon;iry fu11c1 ion decrements.
airway hypcrreactivity. rc.,piratory .,y mptoms, pos.,iblc inneas..:d medication u.,c and physician/cmngency room vi.,-
its among indi viduals with heart or lung disease . rcducL'ci
exercise capaL·ity , increased hospital admi ss ions and possible increased mortality. Similar effects we re felt to occur in
association with airborne particlL·s. with the l'xccption of
inflammatory changes, and with the addition or increaseJ
schoo l absenteeism. Poor data 011 individual exposure were
identified as a limitation of studi..:s on hospital admi.,.,ions
and mo rtali ty.
RECOMMENDATIONS : The panels identified the need to
reflect the evide nce accurately without unduly r;1i .,i11g public concern and r..:comme nded that advisory health message s identify expec ted health elkcts. while health care
providers could more appropriately recommend protective
actions to individuals. Supple mentary educational strat..:gies and evaluation of the advi ., ory program were also
recommended. (Po11r I<' rc;_1-u,11 c. rnir 11ag<' [56)
Key Words: i\cfrisorics. ;\ir 1>01!111io11. ( !:one. S111og
CorrnJJ011dc11ff 111/d n·11ri111s: /),- /)m ·i,I M S1ieh. Air Q1w/11y I /ni/1/1 E/fi'ct., Nc.11·an"/1 Scctio11. Hcalrh Cu11ad11. 1111.,10/ lorn/or ()8()3 (',
Pasture. 01tmra. c)111urio KI i\ IIL2 _ lc!t·11//om' 6/ 3-957-3 132. Fax r,J .i-9-1 I -45-16. c-11wil duff .,ricf,_ut _11c1112()2@isdrc1i3./1\\'C.cu
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C.111nt Pw1cl ji1r rlic Cauwlian S///og Adri.wrr Program. Chu ir: L 0(/\·id Pcngclly Plin. Ocpar1111rnts of J\.frdici11,· 1111d D1gi11ari11g
Phrsics. McMastcr Uni, ·cr.,itr. l'a11c/ 111l'lllil/'rs: /Jarid V Butes lWD FRCP FRCPC FA C P FR.SC. Ol'f>urt1111·11r o( // ca/t// Cure u11rl
£1iidc111io/ogr. Unirl'l'sitr 0(/Jriris/1 c,,J,1111/,iu; Afork Fra1111i1011 MD. D1part111c11t., of Medicine u11d Lm·ir,111111c11t,il Ml'dici11c. l/11i\'!'r.1i1_1· of
Roc/1csrer: Teresa M MtGrurl, MO. ( >111urio Mi11istn· o)Lahow: Andre1v D O.r111a11 MD MSc FRCl'C. De11ar1mc11r., of'Cli11irnl
[11ide111io/ogr and Biostati.l'tic.l' and 1-'wnilr Mcdici11e. McMastc r U11i\'nsity : Mar/.: E Rai:c1111c /!Sc. /1.ir Quality /Im/ti, Ejfcct.l' R,·.1,·un/1
Section . Hcaltlr Cwwda: Lo11 S!in1/i·ld M,-\ PCng. Tl,c Mf:'P Co111pa11_r: Frances Sih·ernw11 fir!). 0 ,•11urtmc11t o(Medicinc. U11i1 'ffsit_r of
Torn11tn: Peter W S11111111r.:r.1 !'Iii). ;\ir Qualirr Rc.1('(/rc/i /Jra11cli. Enrim111111·111 Ca11ada: S Murrin Tur/or P/1/). nc1ium11m1 of(; ,,ogm11l1_1'McM11stcr l/11ircr.,i1r: Sl'r'IT(' Vn lul MU MS,·. Oc/)(Jr//11e11t of'Medicinc. U11i1·c rsit_1· o/'Britisli Co/1111i/1iu
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Can Resp1r J Vol 2 No 3 Fall 1995
155
STIEB ET AL
Effets sur la sante de la pollution atmospherique au Canada : Resultats rapportes par un
groupe d'experts pour le Programme canadien d'avertissement de smog
0BJECTIF : Passer en revue !es prcu ves des eflets sur la sa nte de
la pollution atmospheriqm· puur le Programme canadien d\1verti,;sement de smog.
METHODES : Les preuvcs ont etc examinees par dcux groupcs
d'experts a qui !'on a demandc de dctennincr Ies cffcts attendus
sur la santc [1 des nive;iux d'exposition fourni s par !es objectifs
nationaux afferents f1 la qualite de ['air ambianr, d'cxamincr unc
varietc de question s aya nt trait al 'ini"ormation de la population sur
!cs risques env ironncmentaux pour la sante, et d'cbaucher des
messages sanitai res pour le Programme cl ' averti ssement.
RESULTATS : Les groupes d ' experts ant conclu que lcs effets
sur la sante de !'ozone au ras du sol 11 des niveaux detcctes au
Canada comprennent notammcnt l'int1ammation pulmonaire, la
deterioration de la fon ction pulmonairc, l' hyperreac tivite bro nchiqlll·. de,, .,yrnptflmes respiratoircs . une augmentation possible
T
HE TE RM "SMOG" IIAS BEEN US ED IN NO RT H AME RICA
to describe a characte ristic form or air pollution that
genera lly occurs from late spring to early fall. Smog was
recog nized as a Canadian pollution issue in the fede ral
'Green Plan' in 1990, and in 1993 Env ironment Canada
introduced the Canadia n Smog Advisory Program. T his report presents background infonnation on air pollution in
Canada and summarizes the findings of an e xpe rt panel
process underta ken in support of the Canadian Smog Advisory Program. It is a condensed and modified version of the
original report on the panel process (I). Its purpose is to
provide clinicians and public health workers with the information needed to respond app ropri ately to question s or concerns of patients and members of the pub lic that may he
triggered by snro.!! advisories .
BACKGROUND
Although air 4uality in Canada has generally improved
over the past 15 years, smog episodes still Ol'cur. These
episodes. which are primarily a summer phenomenon. con sist principally of elevated concentrations of gro und-level
ozone. although al'icl aerosol s (a type of airborne particle)
may also be present (2). A different form or smog, 'winter
smog ' , may also lll'l'ur, whose principal constituents are
sulphur dioxide and airborne particles (inl'luding acid aerosols) (2). G round-lewl owne and airbornL· particles were the
focus of the panel process.
Ground- lcwl ('tropospheric') ozone. which should be d istinguished from stratosphcriL· o;:one ('the ozone layer' ). is a
gas that is formed when its precursors, oxides of nitroge n and
hydrocarbons. interact in the aunosphere in the presence of
high temperatures and sun light (3 ). Smog and its precursors
may be transported long distances through the atmosphere
(3) with the result that high concentrations of ground-level
owne may be found in both rural and urban areas (4). Although long range transport contributes significantly to ob156
de !'uti lisa ti on des med icame nt s ct des consultations ti l' urgence
nu chcz le medecin pa rmi !cs individus so ufl'rant d'une affect ion
pulmonairc ou cardiaquc. unc tolera nce rcduitc a r·cxcrcicc. unc
augrnenlat ion des hospitalisations ct aug mentation possible de la
mortalitc . On pense quc des clTcts sirn ilaircs sc produisent en
assoc iation avec !cs pa rticulcs aerogcncs. f1 l'exl'cption des
changemcnts inllammatoircs, ct en y ajoutanl une au gmcn tation de
l'abscnrcismc scolaire. Des donnccs insuflisantcs sur !'exposition
individue lle ant etc iclcnti fiecs comme unc limi ta tion des etudcs
sur lcs hosp italisations et la morta litc.
RF.COMMANOATIONS : Les experts ont id cntilil' le bcsoin de
rclleter correctcmcnt lcs preuvcs sans trop sou lever d'inquietudes
dan s la population et ont recommandc quc !cs mcssagcs-sante
iclentifient lcs e !Tcts attcndus sur la sant c. pendant quc !cs
po urvoy c urs de s soins de santc pourraicnt plus adcqualcmcnt
reco mmancl er des comportemcnts protcctcurs aux indiviclus.
Des strategies cducatives supplcmc nta ircs ct unc evaluation du
Prog ramme d'avc rtisscmcnt ont aussi cte rccommandccs .
Po11r nhtcnir la rcr.1·ion.fi·an(·aise i1111igra!e cl<' <"<'I article. nm11111111i<111ec m •ec f" all/Cur {/ f" adreSSC i11tfi</II ('(' .
served ground-level ozone concentrations in a number or
regions, its impacr is particularly apparent in Atlantic Canada. where peak concentrations may occur at night. In most
other areas, peaks occur during the late afternoon and early
evening in the summer months. In Canada, the current National Ambient Air Quality Object ive for ground-level ozone
(I h maximum of 82 parts per bil lion ippbl - maxim um
acce ptable concen tration) is exceeded most often in southern
Ontario. southern Quebec, Vancouver and southern New
Brunsw ick (5) (Figure I) .
Airborne particles are very smal l pieces of solid or liquid
matter, which vary in si ze, chemical composition and sou1n·.
Smaller particles. which ha ve the greatest health significance, tend to arise fro m man-made sources, particularly fuel
combustion, and include acid aerosols such as sulphates and
nitrates, as well as metal oxides (6). Larger particles consist
mainly of naturally occ urri ng substances. particularly soil
(6). Particles less than IO ~1111 in diameter (PM 10) are considered 'inhalable' (7). T he current National Ambient Air Quality Objective for total suspended particles (TSP - airborne
particles of all sizes) is 120 µg/111 3 for 24 h concentration.
which is still exceeded at least I0 % of the time in some cities
across C anada (5). The current US standa rd fo r PM 10 is 150
µg/rn 3 for 24 h concentration. Recent data reveal 24 h concentrations that e xceed I 00 µg/m 3 in a number o f Canadian
cities (8). Health Canada is currently developing a Canadian
PM 10 objective.
The Smog Advi sory Progra m was introduced in the summer of l 993 under Canada 's G reen Plan as a means of
info1ming the public about both environmental and health
aspects of smog e pisodes. The program was fi rst implemented in Saint John, New Brunswick, in southern Ontario
and in the G reater Vancouver Regional District, and began in
Montreal in 1994. As described earlier, these areas are situated in the geographic reg ions in which the highest groundlevel ozone concentrations have been observed. Under the
Can Respir J Vol 2 No 3 Fall 1995
Health effects of air pollution in Canada
DAYS
30
25
20
15
Io
Io
EDMONTON
I
CALGARY
2.3
WINDSOR 30.0
\J
Figure I) Numhcr of days per year H'ith o:011e /cre/.1 in excess of the f hair quality ohicctirc of 82 pun.1 f>N /Jil/i,m. ,11·cmgc of 1/1/"l'c /1ig/ws1
rears ! ':)83- / 990 (Source : Cm'iro11111e11t Canada. 1994)
program , gro und-level ozone forecasts arc produced cooperativ ely by Environment Canada, the provincial min istries
of environ ment and munic ipal air quality offices. based on
meteorological and air monitoring data. Advi sories are issued
when l h maximum level s are foreca stcd to exceed a specified level, de pend ing on the jurisdiction, but generally
82 ppb. They consist of an environmental message that describes the pollution sources that contribute to smog (chiefl y
automobi le transport) and the need for the public to red uce its
de pe ndency on cars, as well as a health message that advi ses
the public of poss ible health risks associated with smog
exposure. T he exact content of the messages is determined by
provincial environmental and health authoriti es. ln I993 . the
tirst summe r of the prog ram's exi stence, four ad visories were
issued - two in Saint John and one each in southern O ntario
and the Greater Vancouver Regional Di strict. A si milar number of adv isories was issued in 1994. As seen in Figure I. a
sign ifi cantly greater number of episodes of elevated gro undlevel ozone concentrations has occurred in these areas in
previous years.
measurement, and hea lth care delivery. The chair and several
pane l members had independe ntly conducted literature reviews before their participation in the panel s and ke y references were provided to panel members in preparation for
one-clay meetings of each gro up. Each panel was asked to
defi ne the health effects expected at level s of exposure given
hy the National Am bient Air Q uality Objectives; to examine
a variety of issues related to communicating with the puhlic
abo ut env ironme ntal health ri sks: and to draft health me:ssages for the advisory program . Although under the Smog
Advi sory Program . advisories are issued only for groundleve l ozone, e ffects of airborne particles were also L'Onsidered
by the panels . While the same indiv idual chaircd bnth panels .
great care was taken to allmv each group scope to produce
differing conclusions and recommendations . Nonethe less. a
strong concurrence was noted between the findi ngs of the two
pane ls . Once the panels were completed, mi nutes of each
pane l as well as a synthesis were circulated to the panel
me mbe rs for comment and revision .
METHODS
The pane ls considered a variety of evidence on the relati onship between air pollution and health . This included lahorato ry studies, which have examined the pathophysiolog ic:al
mechani sms through which pollutants exert their effects:
chamber stud ies. which ha ve been used to measure various
hu man heal th effects at contro lled exposure· levels: panel
studies, in which (for example) children attending summer
PANEL FINDINGS
Health aspects of the advisory program were addressed for
Health Canada and Environment Canada hy two ex pert panels convened by the Institute of Environment and Health of
McMaster University and the Un ive rsity of Toron to. T he
pane ls compri sed individuals with experience in air po llution
health research . public hcalth, air pollution meteorology and
Can Respir J Vol 2 No 3 Fall 1995
157
STIEB ET AL
'\
Mortality
Hospital
admissions
Emergency room visits
\
\ 6 sc,e,;i,
Physician off ice visits
~
of effect
Reduced physical performance
Medication use
Symptoms
Impaired pulmonary function
Subclinica l ettects
I
I
Proportion of population affected
Figure 2) Schrnulfic rc11J'('sc111a1io11 o{//1e /)/}f<'nlial heal!!, cffcc/s of
air p ol/11 1in11. 1\da1>tccl ll'ith 1>cm,issio11Ji·n1111!1c 1\111crica11 Thoracic
S11cic1r (()J
camp have been followed with respect lo pulmonary function
and ymptom s in relation to ambient pollutant level s: and
studies based on administrative data on emergency room
visits. hospital admissions and mortality and their relationship to cha nging pollutant level s. ll was noted that the latter
·ecologic' studies haw been criticized because they lack
important data on individual exposure. and that in studies or
exposure lo ambient pollution. il has been di ffic ult to sep:iratL'
the effects or individual pollutants. particularly ground-kvel
o;onc and acid aerosols.
The panels conceptual ized the potential health effects or
air pollution as occurring in a logica l \:ascade' or ·pyramid ' .
ranging from severe. uncommon events (cg. death) to mild.
common effects (eg. eye. nose and throat irritation) and
asymrtomatic changes of unclear clinical significance (cg.
small pulmonary function decreme nts and pulmonary inflammation) (9.10). Thus. while according lo this 11H1dcl
SL:vcre health events prec ipitated by air pollution would Ill'
rare. there is a potentially large overall impact on he,lllh and
well -be ing (Figure 2).
Wit h respect lo ground-level 01,one. the panels kit that
cu rre nt palhophysiological evidence suggested that ozone is
associated with an inflammatory response manife sted by
increased airway membrane pe rmeability and bronchial
hype1Teactivity ( 11.12). Some or the nxenl epidemiulogic:11
Iilerature reviewed by the panels indicated that pulmonary
runction measures in children attend ing summer camp in
southern Ontario were reduced on average by 3.5 to 7<1< wlll'Il
I h av erage coneentrations of ground-level 01011L'. reached
140 ppb ( 13) . that approximately 5% of On tario hospital
admissions ror respiratory disease may be attributable lo
elevated conccnlralion.s of ground-level O/\lllC (4.14) (up to
\ 5';{ in those umicr two years of age I in combination with
sulphate particles 1141). and that in Los Angeles the combination of ground-level ozone. nitrogen dioxide and lemperalltre
accounted for 4% of the day lo day variability in mortality
(excluding accidents and suicides) ( 15). Whether the effects
observed in epidemiological studies can be directly allributccl
to inflammatory responses seen in laboratory studies is unclear. The e vidence for chronic effects is also unclear. The
panels concluded that there was some evidence that certain
groups arc more susceptible 10 the acute clTccts or groundlevel ornne. either on the basis of increased sensitivity (lhe
TAB LE 1
Expert panel sum mary of health effects of ground-level ozone
Ground-level ozone concentration (parts per billion - 1 h maximum)*
50-80
80-1 50
>1 50
Air quality descriptor
Ve po_o_r _ _
Good
Fair
Population
Poor
No known
Respiratory symptoms with
Higher probability of
Inflammation of respiratory tract
General popul ation
harmful effects
heavy outdoor exercise in
(adults and children)
effects described in
Decrements in pulmonary function
'poor' category
Airway hyperreactivity
sensitive people
Larg er proportion of population
Respiratory illness in
experiences symptoms with heavy
children with less
intense exercise
outdoor exercise
Reduced capacity for
exercise/physica l work
Probability and severity of expected health effects increases with increasing exposure (time and level)
No known
Above plus possible
Above plus higher probability of
Higher probability of
Individuals with
heart
harmful effects
increased: medication use;
effects described in 'fair' category
effects described in
or lung disease
physician/e mergency room
Possible mortality
·poor' category
(including asthma)
visits; and hospital
admissions
"50 ppb = Maximum desirable concentration: 80 (82) ppb = Maximum acceptable concentration: 150 ppb = Maximum tolerable concentration.
Source reference 1
158
Can Respir J Vol 2 No 3 Fall 1995
Health effects of air pollution in Canada
very young, the elde rly. those with chronic cardiac or resp iratory di sease) or increased expos ure during outdoor activity
(school chi ldren. joggers, cycl ists and other athletes, and outdoor workers such as fann and con struction workers ). However. this was recogni zed as a controversia l area . The panels
differed in their interpretat ion of the evide nce on the occurrence of hann ful effects in the general popu lation at levels
below 80 ppb.
/\ synthesis of the effects ide ntified by the pane ls at con centration s g iven by the Nat ional Ambient Air Q uality O bject ives is presen ted in Table I. Th is table summarizes the
curre nt sc ienti fic ev idence. weigh ing what the panels saw as
the relati ve st rength of the evidence for various effects al
various levels. T he conte nts of the table do not translate the
ev idence into appropriate messages fo r comm unicating with
the gene ral public .
Although the pane ls were not spec ificall y asked to address
the issue or whether there was a threshold concentration for
ground-leve l ozone below which effects wo uld not be ex pected, they were requi red to frame their findi ngs accord ing
to the Nati onal Ambient Air Q uali ty Objectives. whic h inevi tably rai sed the threshold issue. T here was little support
among panel members for the concept of a threshold concentration fo r effec ts of ground-level ozone, which is re fl ected
by their concl usion that the probability and severi ty of e xpected healt h e ffect s increases with increasi ng ex posure (Table I). Howe ver. it was recognized that this was a separate
issue fro m choos ing an adm in istrative th resho ld concentration ( 16) for the purposes of issuing adv isories. The latter
issue was fe lt to be more appropriately addressed by au thorities in the individual regions where advisories are issued (as
described earlier).
W ith respect to airborne parti cles. the panel s felt that the
pat hophysiolog ical mechanism through whi ch they exert
the ir effects on respiratory health was not wel l understood.
Some of the recent epidemiological li terature revie wed by the
pane ls (much of which ori gi nates in the Uni ted S tates ) indicated that e levat ions of PM to concentrations of approximately I 00 to 150 ~tg/mJ are associated with reductions in
peak expiratory !low of up to 6% ( 17.18). approx imately
si xfold increases in medication use :nnong asthmatics ( 18 ).
1. 5- to twofo ld increases in resp iratory symptom reporting
( 17.18), 40% increa ·es in school absentee ism (19). statistically significant increases in respiratory hospital admissions
(20) and up to 16% increases in mortality (excluding accidents and suicide) (21 ). The panels concluded that gro ups
with greatest susceptibility appear to be those with chron ic
cardiac and resp iratory disease, although thi s was recogni zed
as a controversial area. As was the case for grou nd-leve l
ozone, although the panels were not specificall y asked to
address the 4uest ion of the e xi stence or level of a threshold
conce ntration fo r the effects of airborne p;.irtic les. the question again arose beca use the pane l was re4uired to fra me its
fin di ngs acco rd ing to various leve ls of exposure as was done
for ground-leve l ozone. T here was little support among panel
members for the concept of a threshold for the effects or
airborne particle~ .
Can Respir J Vol 2 No 3 Fall 1995
"Ground-level ozone, the major compon ent of smog. is of
primary co ncern because it is a powerful irritant and can
have potentially harmful effects on the respiratory system .
Symptoms are most likely to occur in individuals who are
physically active outdoors . People with heart or lung
disease. especially asthma, may experience a worsening
of thei r condition ."
··commonly reported symptom s include irritation of the nose
and throat, cough , and chest tightness . Minimize your
exposure by avoiding outdoor exercise particularly in the
afternoon and early evening when ground-level ozone
concentrations tend to be at their highest."
"Children tend to be more sensitive tt1 an adults because
they breathe faster and in the summ er spend more time
outdoors being physically active. Reduce your child's
exposure by encouraging outdoor activities early in the day
when pollutant levels are lower."
Figure 3) Sa111r1le of public info mwri, 111 111essagcs //la de arnilahlc
hy Health Cllnlldu to s11p1,le111e111 Slllog i\drisory Prograill /1/Cssllgcs. S011ffc refere11cc 22
PANEL RECOMMENDATIONS
W hile the panels made a nu mber of wide -ranging recomme ndations, onl y those relating to the content of health messages and their implementation are summarized here.
W ith respect to the conten t o f health messages, pa,1icul ar
issues ide ntified by the pane ls included the followi ng: appro priate emphasis fo r ' diagnos tic' versus ' prescriptive ' messages (those that ident ify expected health e ffects versus those
that recommend protective ac tions): identification of target
groups: ensu ring that messages accurate ly re flect the scienti fic evidence and do not unduly raise public concern: and
selection of an appropriate threshold for the ground-level
ozone ad visory. In consultation with provinc ial public health
authorities. it was strongly recommended that the health
messages be diagnos tic only, wi th the recommendation that
more spec ific prescriptiw adv ice be obtai ned from local
public health autho rities and/or personal health care providers fam iliar with the individua l' s clinical history.
W ith respect to implen11:·ntation aspects of the advisory
program. the panels recommended suppl ementary education
strategies di rected towards indiv iduals at risk as we ll as
pare nts , teachers. athletes, coaches, health professionals and
public health officials, and identified the need for evaluation
of the impact of the advisory program.
In response to these recommendations Health Canada has
deve loped a series of supplementary public informat ion messages, which ha ve been made available to the public in both
official languages through the media. physicians ' offices,
hospi tals and parenting magazines (sec Figure 3 for sample
messages ). In addition, Health Canada is col laborat ing with
Environment Canada in conducting public surveys to evaluate vario u · aspects of the adv isory program. includ ing awareness of advisories and ad visory-related changes in behaviour.
159
STIEB ET AL
'>. Ameri can Thoracic Society. G uidel ines as to what constitull's
CONCLUSIONS
The expert pane l process se rved as a rapid means of
ide nti fying and interpreti ng the e vidence on health e ffects
grou nd-le ve l ozone and a irbo rne partic les . Mo unting evidence was identified linking e le va ted concentrat ions of these
pollutants with a spectrum of harmful effects on health, and
recomme ndations were made regarding e ffectiv e communication with the public about these risks.
Note: The original report of the pane ls (refe rence I). including a de tailed refere nce list, as we ll as public information
materia ls on various air pollutants, arc available t'rom the
corres pond ing author.
or
I 0.
I I.
12.
IJ.
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