Proposal of new ICD code for suicide by charcoal burning

The evolution of charcoal-burning suicide: A systematic scoping review

INTRODUCTION

Suicide by charcoal burning has accounted for more than 100,000 deaths. It has become an increasingly common suicide method in Hong Kong since first reported in 1998, and it has spread into South Korea, Taiwan, Japan and other countries. This systematic scoping review aimed to explore current evidence on trends, risk factors, impact of media and prevention strategies for this suicide method, and to identify research gaps.

METHODS

A search for articles published from January 1998 to June 2021 was conducted through electronic databases (MEDLINE, EMBASE, SCOPUS and PsycINFO) with the keywords (suicide*) AND (charcoal). Articles describing prevalence, trends, characteristics, risk factors and prevention strategies of charcoal burning suicide deaths were included. Non-peer-reviewed articles, non-English articles, commentaries/editorials/letters, poster abstracts, reviews, meta-analyses and studies that documented only charcoal burning suicide attempters/survivors were excluded.

RESULTS

Eighty-eight studies were identified, most from East Asia. Charcoal burning suicide rates in Hong Kong, Taiwan and Japan has passed the peak, while continuing to increase in South Korea. Risk factors are changing and not static. Media appears to play an important role in triggering and spreading information. Restricting access to charcoal, and raising public awareness have been effective in the short term in preventing charcoal burning suicide, but there is little information on their long-term effectiveness or sustainability.

DISCUSSION

More research is required to update the development and dynamic changes of charcoal burning suicide and the contributing factors. The evidence from this review may assist in detecting and intervening early for future novel suicide methods.

The differential impacts of social deprivation and social fragmentation on suicides: A lesson from Hong Kong

INTRODUCTION

Little research has conducted to examine the association between social deprivation and social fragmentation, overall and method-specific suicide risk, and how these associations may change over time. This study investigated the association between social deprivation and social fragmentation with overall and method-specific suicide in Hong Kong from 1999 to 2018.

METHODS

Suicide death data of each small tertiary planning unit (STPU) was obtained from the Census and Statistics Department of Hong Kong. Socio-economic characteristics in STPU level were obtained from Census and Bi-census. Exploratory principal component analysis was used to construct the social deprivation (SDI) and social fragmentation indices (SFI) based on the socio-economic characteristics. Bayesian hierarchical modelling was conducted to explore the association between SDI and SFI with overall and method-specific suicide over time, controlling for population density and male-to-female ratio.

RESULTS

Higher risk of suicide was generally observed around Kowloon Peninsula and some parts in the Northern, Northwestern and Southwestern areas depending on methods. The effect of SDI and SFI on suicide risk varied by years and methods. In 2014-2018, for every 10% increase in SDI, the suicide risk for overall, jumping, hanging, and charcoal burning elevated by 22% (95%Crl = 10%-37%), 26% (95%Crl = 12%-41%), 31% (95%Crl = 14%-51%), and 21% (95%Crl = 4%-42%) respectively.

CONCLUSION

Spatial variations and effects of SDI and SFI on overall and method-specific suicide risks varied by different periods. SDI was observed to be a stronger factor in the recent years. Situations should be monitored, and interventions should be implemented and adjusted accordingly to the changes.

Quantifying the contributions of age, sex, methods, and urbanicity to the changing suicide rate trends in South Korea, 2001-2016

PURPOSE

Suicide rates in South Korea have been one of the highest in the world. The aim of this study is to quantify the contributions of age, sex, method, and place of residence to the trends of the suicide rates between 2001 and 2016 in South Korea.

METHODS

Using the suicide data obtained from the South Korean National Death Registration data set for the years 2001-2016, a Joinpoint regression analysis was conducted to determine if there was a significant change in the trend of suicide rates. Next, a decomposition analysis method was used to quantify the contributions of age, sex, method, and places of residence to the changes in the suicide rates.

RESULTS

Suicide rates increased between 2001 and 2010, and decreased between 2010 and 2016. Among all the age groups, the 65-79 age group contributed most to the rise (18% in men and 7% in women) and fall (- 15% in men and - 14% in women) of suicide rates. Men contributed much more than women to the increasing trend of suicide rate (63.0% vs. 37.0%). Hanging was the key method of suicide, dominating the ups and downs of the suicide rates. The rates of suicide by pesticide poisoning have been decreasing since 2005 and suicide by charcoal burning continued to increase against a decreasing trend of suicide rate during the period of 2010-2016. The gap of the metropolitan-city-rural suicide rates was narrowing during the period under study, although the rural areas remained to have the highest suicide rates.

CONCLUSION

The ups and downs of suicide rates in South Korea were not uniform across different sociodemographic groups. Age, sex, method, and place of residence contributed differently to the changes in suicide rates. Suicide prevention measures can be more focused on certain age-sex-method-region subgroups.

Risk of dementia after charcoal-burning suicide attempts: a nationwide cohort study in Taiwan

This study aimed to investigate the association between charcoal-burning suicide attempts and the risk of developing dementia. A nationwide, matched cohort, population-based study enrolled a total of 4103 patients with newly diagnosed charcoal-burning suicide attempts, between 2000 and 2010, which were selected from the National Health Insurance Research Database of Taiwan, along with 12,309 controls matched for sex and age. After adjusting for confounding factors, Fine and Gray's competing risk analysis was used to compare the risk of developing dementia during the 10-year follow-up period. Of the enrolled patients (n=16,412), dementia developed in 303 (1.85%), including 2.56% in the study group (105 in 4103) and 1.61% (198 in 12,309) in the control group. The Fine and Gray's survival analysis revealed that the patients with charcoal-burning suicide attempts were likely to develop dementia, with a crude HR of 5.170 (95% CI 4.022 to 6.644, p<0.001). After adjusting for age, sex, comorbidity, geographic area and urbanization level of residence, and monthly insured premium, the adjusted HR was 4.220 (95% CI 3.188 to 5.586, p<0.001). Suicide attempts were associated with an increased risk of degenerative dementia in this study. Patients with charcoal-burning suicide attempts had a fourfold risk of dementia than the control group.

The trend in suicide methods in South Korea in 1997-2015

South Korea exhibited the highest crude suicide rate in the world. To better understand this phenomenon, the author analyzed all suicides in South Korea from 1997 to 2015 and charted the trend in suicide methods by gender. Over time, both genders rapidly chose hanging for suicide at the expense of drug/pesticide poisoning. Gassing was hardly used in the beginning, but its recent gain in use is noteworthy. Including undetermined deaths did not change the main results. The author regressed hanging on demographics and found that hanging was particularly chosen by ever-married men of prime working age with a respectable level of education.

Spatial and temporal evolution of the epidemic of charcoal-burning suicide in Japan

PURPOSE

An epidemic of carbon monoxide poisoning suicide by burning charcoal occurred in Hong Kong and Taiwan. An epidemic also emerged in Japan from February 2003 and resulted in an increase of 10-20 % in overall suicide rates in younger adults (aged <45 years) in the mid-2000s. We investigated the spatial and temporal evolution of the epidemic to assess its impact on the epidemiology of suicide in Japan.

METHODS

Mortality data were obtained from the official vital statistics of Japan. Smoothed standardized mortality ratios of charcoal-burning and non-charcoal-burning suicide were estimated for the period 2003-2013 using Bayesian hierarchical models. Joinpoint regression analysis was performed to analyze secular trends in suicide rates by gender, method used and geographic location between 1999 and 2013.

RESULTS

Suicide by burning charcoal rose sharply in the mid-2000s and was not accompanied by a simultaneous decline in alternative methods. The epidemic of charcoal-burning suicide in Japan showed a pronounced spatial pattern, being concentrated in rural prefectures particularly among males. For men but not women, the epidemic contributed to the widening of urban-rural disparities in suicide rates (higher rates in rural areas).

CONCLUSIONS

Our results differ from previous research in other Asian countries (e.g., Taiwan), where the epidemic of charcoal-burning suicide emerged more prominently in urban areas. In Japan, the introduction and diffusion of charcoal burning contributed to a real excess in suicide rates, as well as a widening of the urban/rural disparity in suicide.

Epidemic of charcoal burning suicide in Japan

BACKGROUND

The charcoal burning suicide epidemics in both Hong Kong and Taiwan have been well documented. However, little is known about the situation in Japan.

AIMS

To examine the impact of charcoal burning suicide on the overall and other method-specific suicide rates between 1998 and 2007 in Japan.

METHOD

Using data obtained from the Vital Statistics of Japan, negative binomial regression analyses were performed to investigate the impact of the charcoal burning method.

RESULTS

In males and females aged 15-24 and 25-44 years, the charcoal burning epidemic led to a substantial increase in overall suicides, without a decrease in other methods. In all other age groups, no such trend was observed.

CONCLUSIONS

In young Japanese, the charcoal burning method may have appealed to individuals who might not have chosen other highly or relatively lethal methods, and consequently led to an increase in overall suicides.

Assessing the Efficacy of Restricting Access to Barbecue Charcoal for Suicide Prevention in Taiwan: A Community-Based Intervention Trial

OBJECTIVE

Charcoal-burning suicide has recently been spreading to many Asian countries. There have also been several cases involving this new method of suicide in Western countries. Restricting access to suicide means is one of the few suicide-prevention measures that have been supported by empirical evidence. The current study aims to assess the effectiveness of a community intervention program that restricts access to charcoal to prevent suicide in Taiwan.

METHODS AND FINDINGS

A quasi-experimental design is used to compare method-specific (charcoal-burning suicide, non-charcoal-burning suicide) and overall suicide rates in New Taipei City (the intervention site, with a population of 3.9 million) with two other cities (Taipei City and Kaohsiung City, the control sites, each with 2.7 million residents) before (Jan 1st 2009- April 30th 2012) and after (May 1st 2012-Dec. 31st 2013) the initiation of a charcoal-restriction program on May 1st 2012. The program mandates the removal of barbecue charcoal from open shelves to locked storage in major retail stores in New Taipei City. No such restriction measure was implemented in the two control sites. Generalized linear regression models incorporating secular trends were used to compare the changes in method-specific and overall suicide rates before and after the initiation of the restriction measure. A simulation approach was used to estimate the number of lives saved by the intervention. Compared with the pre-intervention period, the estimated rate reduction of charcoal-burning suicide in New Taipei City was 37% (95% CI: 17%, 50%) after the intervention. Taking secular trends into account, the reduction was 30% (95% CI: 14%, 44%). No compensatory rise in non-charcoal-burning suicide was observed in New Taipei City. No significant reduction in charcoal-burning suicide was observed in the other two control sites. The simulation approach estimated that 91 (95%CI [55, 128]) lives in New Taipei City were saved during the 20 months of the intervention.

CONCLUSION

Our results demonstrate that the charcoal-restriction program reduced method-specific and overall suicides. This study provides strong empirical evidence that restricting the accessibility of common lethal methods of suicide can effectively reduce suicide rates.

The diffusion of a new method of suicide: charcoal-burning suicide in Hong Kong and Taiwan

PURPOSE

In the late 1990s, an epidemic rise in suicides by carbon monoxide poisoning from burning barbecue charcoal began in Hong Kong and Taiwan. This study investigates the diffusion of this new method of suicide.

METHOD

Official mortality data for 1998-2010 in Taiwan and 1998-2009 in Hong Kong were collected; overall and method-specific suicide rates in different socio-demographic subgroups over the study period were compared. Multiple logistic regression analyses were conducted to assess the socio-demographic risk factors for charcoal-burning vs. non-charcoal-burning suicide.

RESULTS

In Hong Kong, the incidence of charcoal-burning suicide increased steeply within 1 year of the first reported cases, but its use has declined from 24.2% of all suicides during the peak period (2002-2004) to 17.1% (2007-2009); in Taiwan, the pace of diffusion was slower in onset, but it remains a popular method accounting for 31.0% of all suicides in 2008-2010. The early adopters in both places tended to be young- and middle-aged men. As the epidemic progressed, the method has also been gradually adopted by older age groups and women, particularly in Taiwan, but in 2009/10, the method still accounted for <8% of suicides in those aged >60 years in both areas.

CONCLUSIONS

Common features of the epidemic in both places were the greater levels of early uptake by the young- and middle-aged males. The different course of the charcoal-burning suicide epidemic may reflect social, geographic and media reporting differences. Surveillance to identify the emergence of new suicide methods is crucial in suicide prevention.

Regional changes in charcoal-burning suicide rates in East/Southeast Asia from 1995 to 2011: a time trend analysis

BACKGROUND

Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995-2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries.

METHODS AND FINDINGS

We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996-2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997-1999), followed by Singapore in 1999 (95% CI 1998-2001), Taiwan in 2000 (95% CI 1999-2001), Japan in 2002 (95% CI 1999-2003), and the Republic of Korea in 2007 (95% CI 2006-2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15-24 y in Japan and people aged 25-64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study.

CONCLUSIONS

Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method. Please see later in the article for the Editors' Summary.

Regional changes in charcoal-burning suicide rates in East/Southeast Asia from 1995 to 2011: a time trend analysis

BACKGROUND

Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995-2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries.

METHODS AND FINDINGS

We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996-2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997-1999), followed by Singapore in 1999 (95% CI 1998-2001), Taiwan in 2000 (95% CI 1999-2001), Japan in 2002 (95% CI 1999-2003), and the Republic of Korea in 2007 (95% CI 2006-2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15-24 y in Japan and people aged 25-64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study.

CONCLUSIONS

Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method. Please see later in the article for the Editors' Summary.

The impact of a celebrity's suicide on the introduction and establishment of a new method of suicide in South Korea

Unlike other East Asian countries, South Korea has until recently experienced relatively few charcoal burning suicides. We investigated trends in charcoal burning suicide immediately following the suicide by charcoal burning of the South Korean celebrity-Ahn Jae-Hwan-in September 2008. In the study, we compared the weekly number charcoal burning suicides 1 year before and after the celebrity's death. Before Ahn Jae-Hwan's suicide, charcoal burning accounted for <1% of suicides; his death was followed by an immediate and sustained increase in the use of this method-it accounted for nearly 5% of suicides (n = 772 suicides) in the subsequent 12 months. The demographic patterning (young male predominance) and location (inside cars) of the charcoal burning suicides further supported a copy-cat effect. Ahn Jae-Hwan's death appears to have triggered a rapid and sustained adoption of charcoal burning as a method of suicide in South Korea.

Suicide by burning barbecue charcoal in England

BACKGROUND

Suicide by carbon monoxide poisoning from burning barbecue charcoal has become a common method of suicide in several Asian countries over the last 15 years. The characteristics of people using this method in Western countries have received little attention.

METHOD

We reviewed the inquest reports of 12 English Coroners (11% of all Coroners) to identify charcoal-burning suicides. We compared socio-demographic and clinical characteristics of suicide by charcoal burning occurring between 2005 and 2007 with suicides using other methods in 2005.

RESULTS

Eleven charcoal-burning suicides were identified; people using this method were younger (mean age 33.4 versus 44.8 years, P = 0.02), and more likely to be unemployed (70.0 versus 30.1%, P = 0.01) and unmarried (100 versus 70%, P = 0.04) than those using other methods. Charcoal-burning suicides had higher levels of contact with psychiatric services (80.0 versus 59.1%) and previous self-harm (63.6 versus 53.0%) compared with suicides using other methods, but these differences did not reach conventional levels of statistical significance. Over one-third of people dying by charcoal burning obtained information on this method from the Internet.

CONCLUSIONS

Working with media, including Internet Service Providers, and close monitoring of changes in the incidence of suicide using this method might help prevent an epidemic of charcoal-burning suicides such as that seen in some Asian countries.

Suicide methods in Asia: implications in suicide prevention

As the largest continent in the World, Asia accounts for about 60% of World suicides. Preventing suicide by restricting access to suicide methods is one of the few evidence-based suicide prevention strategies. However, there has been a lack of systematic exploration of suicide methods in Asian countries. To amend this shortage, the current review examines the leading suicide methods in different Asian countries, their trend, their age- and sex- specific characteristics, and their implications for suicide prevention. In total, 42 articles with leading suicide methods data in 17 Asian countries/regions were retrieved. The epidemiologic characteristics and recent trends of common suicide methods reflect specific socio-cultural, economic, and religious situations in the region. Common suicide methods shift with the introduction of technologies and constructions, and have specific age- or sex-characteristics that may render the restriction of suicide methods not equally effective for all sex and age sub-groups. Charcoal burning, pesticide poisoning, native plant poisoning, self-immolation, and jumping are all prominent examples. In the information society, suicide prevention that focuses on suicide methods must monitor and control the innovation and spread of knowledge and practices of suicide "technologies". It may be more cost-effective to design safety into technologies as a way of suicide prevention while there is no rash of suicides yet by the new technologies. Further research on suicide methods is important for public health approaches to suicide prevention with sensitivity to socio-cultural, economic, and religious factors in different countries.

The leading methods of suicide in Taiwan, 2002-2008

Background

Diverse socioeconomic and cultural developments between geographic regions and cities/counties have resulted in different physical availability and socio-cultural acceptability of certain methods of suicide. This study examined the changes in distribution of the leading methods of suicide across cities/counties in Taiwan between 2002-04 and 2006-08.

Methods

Mortality data for all deaths classified as suicide or as of undetermined intent from 2002 through 2008 were extracted for analysis. The number of deaths and proportion of completed suicides by four main methods were calculated in order to identify the leading lethal methods in each city/county.

Results

Hanging was the leading method of suicide in 18 out of 22 cities/counties in 2002-04 but decreased to 10 out of 22 in 2006-08. On the other hand, charcoal burning was not the leading method in any city/county in 2002-04 but increased to 10 out of 22 in 2006-08. The younger the age of the deceased, the more likely the leading method of suicide changed from 2002-04 to 2006-08. Charcoal burning was the most often used method in most cities/counties among those aged 15-44; however, hanging was most frequent for those aged 45 or above. Pesticides were the leading method for the elderly in five counties with a high percentage of agricultural population in 2006-08.

Conclusion

The leading method of suicide varied by age group and changed from 2002-04 to 2006-08 in Taiwan. This was due primarily to changes in socio-cultural acceptability of the use of charcoal burning as a method for suicide by younger age groups.