80 Prevention of suicide due to charcoal burning

A new method for suicide, charcoal-burning poisoning, was initiated in Hong Kong in 1998, and has replaced hanging as the second most commonly used method of suicide in the last five years. It has also spread to other regions, for example, Taiwan and Japan. Furthermore, the use of charcoal-burning suicide has drawn a new cohort of individuals into the suicide population. The profiles of the charcoal-burning poisoning death are different from the non-charcoal-burning deaths: there are more males, less psychiatric illness and more financial problems among these cases. Restricting access to charcoal has been proposed to reduce the number of charcoal-burning deaths. The idea is not to completely remove it from the market, but rather to set up barriers to obtaining the suicide means. This means that there is a wider window of opportunity for intervention.

Since 1998, Hong Kong has experienced a new method of suicide: charcoal-burning poisoning suicide. Usually this is done indoors, generally in a small sealed room by inhaling the fumes of carbon monoxide generated by charcoal burning—about 80 per cent of charcoal-burning deaths occur at home. This method accounted for 2.0 per cent of suicide deaths in 1998, rising to 26.4 per cent in 2003 (see Figure 80.1; Yip and Lee 2007). It has replaced hanging as the second most frequently used suicide method in Hong Kong. Furthermore, charcoal burning suicide is not a local phenomenon restricted to Hong Kong. One of the first charcoal-burning suicide victims occurred in Taiwan in 1999, and the individual stated explicitly in his suicide note that he had learned this method from reading a Hong Kong newspaper on the Internet. Since then, the number of suicide deaths resulting from charcoal burning ranked first in Taipei City in 2005, and on a territory-wide level in 2006. At the same time, Taiwan has experienced an historically high suicide rate—20.0 per 100.000 in 2006—which is more than three times the rate during 1993 (6.3 per 100,000). The increase is mainly attributable to the suicide death from charcoal-burning poisoning. Suicide deaths by other means have not increased at similar rates.

Yip and Lee (2007) and Kuo et al. (2008) revealed that the sociodemographic and clinical characteristics of charcoal-burning suicide victims are distinct from those of other cases. The charcoal-burning suicide victims are predominately aged 25–54, mostly men, unmarried and had relatively less history of substance abuse or other mental disorders. They were more likely to have financial troubles (see also Lee et al. 2002; Chan et al. 2005; Liu et al. 2007). Macau, the formerly Portuguese colony located 70 kilometres south-west of Hong Kong, has also reported twelve deaths by charcoal burning, out of the sixty suicide deaths in 2000 (Macau Daily 2000). Japan too reported a significant increase in suicide deaths due to charcoal burning, from less than 1 per cent to about 7 per cent (Takahashi 2008).

Charcoal burning has also commonly been used in suicide pacts in Hong Kong and Taiwan. In 2002 and 2003, 20 of 22 suicide pacts (91 per cent) used charcoal burning (Lee et al. 2005). Previous studies have shown that the methods of suicide used by suicide pacts are generally less violent, and the most common means is poisoning by fumes (Rajagopal 2004). Several perceived characteristics of charcoal burning make it attractive in suicide pacts. Charcoal burning is often portrayed as painless and effective, and hence, passive partners in suicide pacts could be more easily enticed into the act. It is non-disfiguring and is often perceived as a romantic and easy form of death. The messiness and pain associated with gunshots, jumping, hanging or drug poisoning are likely to discourage the submissive participants in a pact. Furthermore, unlike other methods of suicide, such as jumping from heights and hanging, it can easily be shared.

Charcoal is readily available in local markets, supermarkets and convenience stores in Hong Kong. However, it is not an essential and daily household item. It is mainly used for recreational activities (outdoor barbecue especially in Hong Kong) or religious ritual practice (especially in Taiwan for worshipping ancestors). Restriction of the easy access to charcoal is one of the possible prevention methods, and it is also a method that is consistent with international standards of best practice for suicide prevention. Indeed, restricting access to the methods of self-inflicted death has received very strong support both from the World Health Organization (WHO 2001; Hendin et al. 2008) and the International Association for Suicide Prevention (Mishara 2006). One suggestion is to remove the charcoal from open shelves, thus, making it necessary for the customer to ask a shop assistant to obtain charcoal for purchase. Such a restriction could be useful. The idea is not to completely remove it from the market, but to set up barriers to obtain the suicide means. This means that there is a wider window of opportunity for intervention.

In Hong Kong, we have launched a pilot study among all supermarkets and convenience stores in one district. A restriction of charcoal sales has been imposed by removing it from the open shelves of stores in this district. Preliminary results have suggested that this simple restriction has reduced charcoal-burning suicides, as opposed to a comparable district which does not use this measure. Nor is there any obvious substitution for other methods. This is not a question of no access; rather this is a proposal to slow access for those who would seek charcoal at a time of heightened distress.

Research evidence has also shown that restricting access to a specific method of suicide can often lead to fewer deaths. One classic example was a change in the nature of cooking gas in the United Kingdom (Kreitman 1976): a more recent effort involved a change in the packaging of paracetamol in UK, which led to a decrease in deaths from paracetamol poisoning by 21 per cent (Hawton 2002). Also, building barriers on a bridge in New Zealand (Beautrais 2001) (similar to a previously successful effort in Canada), gun safety training in the US (Hemenway et al. 1995), and restricting the sales of specific lethal pesticides in mainland China have been suggested as methods for suicide prevention (Pearson et al. 2002; Yip et al. 2008).

It is particularly important to understand that, based on our monitoring of Hong Kong's suicides, the use of charcoal burning has not been a substitute for other methods (Yip and Lee 2007). The extent to which a society is prepared to impose relatively minor restrictions on all members (which might cause some inconvenience), in order to protect a minority of people who are mentally ill or severely distressed is a reflection of that society's compassion and kindness to its vulnerable fellow citizens.

Suicide is a very complex phenomenon that requires multilayered interventions. Education in life skills, providing and improving services for persons who suffer from medically significant depression, and aiding individuals and families at times of turmoil or distress are all important steps that must be taken. Nevertheless, restricting means is one proven method that has been shown to be cost-effective and relatively simple to implement when it is supported by the community. Thus, we strongly advocate the development of a concerted, sustained and collective approach to suicide prevention that uses, among others things, strategies to control means of suicide (e.g. charcoal sales) as one of its important tools.