Suicide by charcoal burning: a digital age phenomenon.

Charcoal burning is a method of suicide that has only recently been identified, but now attributes to a significant an ever-increasing number of suicides. Before 2000, this method was relatively unknown and the exact mechanism of death unclear. Media coverage has more recently raised awareness of the phenomenon (Chen et al., 2016). The method involves burning of barbecue charcoal in a confined space, leading to carbon monoxide (CO) poisoning (Chen, Yip, Lee, Gunnell, & Wu, 2015). Charcoal is particularly predisposed to smouldering, which results in less effective combustion and more CO emissions than CO2 (Schmitt, Williams, Woodard, & Harruff, 2011). So recent is the uptake of this method that charcoal burning, that it still lacks a specific code under the International Classification of Diseases 10th Edition (Ji, Hong, Stack, & Lee, 2014). Correct categorisation of suicide by charcoal burning is unlikely to persist. A sharp rise was noted in the incidence of charcoal burning in the early 2000s in Japan (Yoshioka, Saijo, & Kawachi, 2016). Following the first reported case of a 38-year old woman in Hong Kong, in 1998 (Liu et al., 2007), it is now one of the most common modes of suicide in Asia, accounting for 20% of all suicides in Hong Kong and Taiwan. In Japan, it accounts for 12.8% of male suicides and 5.9% of females (Kato et al., 2013), with increases also noted in South Korea, Singapore (Cheng, Chang, Guo, & Yip, 2015) and Taiwan, where this method increased 65-fold between 1995 and 2011 (Chang, Kwok, Cheng, Yip, & Chen, 2015). This increase in charcoal suicides in Hong Kong have not been compensated by decreases in other methods, indicating that the availability of this method of suicide may be contributing to increased suicide rates (Liu et al., 2007). Its influence has also been felt in Western nations, with a study in Washington, United States, finding that charcoal burning was increasing with a correlated decrease in suicide by automotive exhaust fume inhalation (Schmitt et al., 2011). Although the study happened to be in a community with the largest Asian population in the USA, the highest incidence was 88% amongst Whites, suggesting no transnational nor cultural boundaries in this area. The concentration of suicides by charcoal burning in Asia and the acceptance of this method by non-Asians in a Western community suggests increased rates of suicide by this method as awareness increases outside of Asia. The emergence and increasing rates of suicide by charcoal requires explanation. Several authors have highlighted the increased accessibility of charcoal for cooking and heating purposes (Cheng et al., 2015), the inexpensiveness of acquiring charcoal (Schmitt et al., 2011), the higher degree of effectiveness (and therefore mortality) than alternatives such as hanging (Ji et al., 2014). The increase in charcoal burning as a mode of suicide has occurred in parallel with the effectiveness of efforts to decrease the toxicity of car exhaust fumes via use of catalytic converters (Schmitt et al., 2011). So convenient and effective is the method of charcoal burning that one Japanese study revealed that increased charcoal burning suicide occurred over a period where the rate of suicide had an overall increase, indicating that acceptance of this method had resulted in more suicides (Yoshioka et al., 2016). The media and Internet have played a significant role in the rising use of charcoal burning as a form of suicide. Over the last two decades there has been a significant rise in the use of the Internet, particularly in Asia, and this has resulted in detailed technical information about methods of suicide becoming readily available to a wide audience (Chang et al., 2015; Cheng et al., 2015). One study found that an increase in Google search volume relating to charcoal burning was related to the incidence of suicide by this method in that same week as suicides increased and in the week following this change (Chang et al., 2015). A further study noted that of the 18 wiki-style pages that detailed suicide methods, none encouraged a person considering suicide to seek help (Cheng et al., 2015). This ready access to information is amplified during periods of media focus on the topic of suicide by charcoal burning. A study in Taiwan found that 87% of survivors of a suicide attempt by charcoal burning had been influenced by media coverage (Chang et al., 2015). The authors observed that the substance of media reporting promoted this method as one that was painless and effective, thereby increasing its appeal to this audience, a finding echoed by Chen et al. (2016). Chen et al. (2016) found that the first news report of a suicide by charcoal burning in Hong Kong described the method in detail and hence it is likely that media influence can increase the cognitive availability of methods in those with suicidal ideation. Media exposure of this particular suicide was then observed to have resulted in a copycat suicide in Taiwan (Ji et al., 2014). Chang et al. (2015) found that in the early stage of the charcoal burning uptake (1998–2000) one media article on the issue was associated with a 16% increase in the use of this method on the following day. The impact of media is amplified by the reporting of “celebrity suicide”. Much research has focused on the impact of a person with a public profile using a particular form of suicide and the resulting trends in choice of method by others in the immediate aftermath. Cheng et al. (2015) identified that after the death by charcoal burning by a notable South Korean actor in 2008 the rate of charcoal burning rose from 0.7% at that time to 7.9% in 2011. DOI: 10.1111/jan.13531