Title The evolution of the epidemic of charcoal-burning suicide inTaiwan : A spatial and temporal analysis

Background: An epidemic of carbon monoxide poisoning suicide by burning barbecue charcoal has occurred in East Asia in the last decade. We investigated the spatial and temporal evolution of the epidemic to assess its impact on the epidemiology of suicide in Taiwan. Methods and Findings: Age-standardised rates of suicide and undetermined death by charcoal burning were mapped across townships (median population aged 15 y or over = 27,000) in Taiwan for the periods 1999–2001, 2002–2004, and 2005–2007. Smoothed standardised mortality ratios of charcoal-burning and non-charcoal-burning suicide and undetermined death across townships were estimated using Bayesian hierarchical models. Trends in overall and method-specific rates were compared between urban and rural areas for the period 1991–2007. The epidemic of charcoalburning suicide in Taiwan emerged more prominently in urban than rural areas, without a single point of origin, and rates of charcoal-burning suicide remained highest in the metropolitan regions throughout the epidemic. The rural excess in overall suicide rates prior to 1998 diminished as rates of charcoal-burning suicide increased to a greater extent in urban than rural areas. Conclusions: The charcoal-burning epidemic has altered the geography of suicide in Taiwan. The observed pattern and its changes in the past decade suggest that widespread media coverage of this suicide method and easy access to barbecue charcoal may have contributed to the epidemic. Prevention strategies targeted at these factors, such as introducing and enforcing guidelines on media reporting and restricting access to charcoal, may help tackle the increase of charcoal-burning suicides. Please see later in the article for the Editors’ Summary. Citation: Chang S-S, Gunnell D, Wheeler BW, Yip P, Sterne JAC (2010) The Evolution of the Epidemic of Charcoal-Burning Suicide in Taiwan: A Spatial and Temporal Analysis. PLoS Med 7(1): e1000212. doi:10.1371/journal.pmed. 1000212 Academic Editor: Phillipa J. Hay, University of Western Sydney, Australia Received June 17, 2009; Accepted November 24, 2009; Published January 5, 2010 Copyright: 2010 Chang et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors received no specific funding for the study. We wish to acknowledge the support for S-SC’s PhD study from the Taiwanese government (the Government Funds of the Ministry of Education), the Higher Education Funding Council for England (Overseas Research Scholarship), and University of Bristol (University of Bristol Postgraduate Research Scholarship). DG is a National Institute for Health Research (NIHR) Senior Investigator. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: SMR, standardised mortality ratio. * E-mail: shu-sen.chang@bristol.ac. uk PLoS Medicine | www.plosmedicine. org 1 January 2010 | Volume 7 | Issue 1 | e1000212