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Soc Psychiatry Psychiatr Epidemiol (2015) 50:14511461

DOI 10.1007/s00127-015-1057-7

ORIGINAL PAPER

The association of trends in charcoal-burning suicide with Google


search and newspaper reporting in Taiwan: a time series analysis
Shu-Sen Chang1,2,3 Simon Sai Man Kwok4 Qijin Cheng2

Paul S. F. Yip2,3 Ying-Yeh Chen5,6,7

Received: 24 November 2014 / Accepted: 1 April 2015 / Published online: 10 April 2015
Springer-Verlag Berlin Heidelberg 2015

Abstract were used to examine the associations between these


Purpose Some East/Southeast Asian countries have ex- variables.
perienced a rapid increase in suicide by charcoal burning Results In the fully adjusted models, every 10 % increase
over the past decade. Media reporting and Internet use in Google searches was associated with a 4.3 % [95 %
were thought to contribute to the epidemic. We investi- confidence interval (CI) 1.17.6 %] increase in charcoal-
gated the association between method-specific suicide in- burning suicide incidence in the same week, and a 3.8 %
cidence and both Internet search volume and newspaper (95 % CI 0.47.2 %) increase in the following week. A
reporting in Taiwan. one-article increase in the United Daily was associated
Method Weekly data for suicide, suicide-related Google with a 3.6 % (95 % CI 1.55.8 %) increase in charcoal-
search volume, and the number of articles reporting suicide burning suicide in the same week. By contrast, non-char-
in four major newspapers in Taiwan during 20082011 coal-burning suicide was not associated with Google search
were obtained. Poisson autoregressive regression models volume, but was associated with the Apple Dailys re-
porting in the preceding week.
Conclusions We found that increased Internet searches
Electronic supplementary material The online version of this for charcoal-burning suicide appeared to be associated with
article (doi:10.1007/s00127-015-1057-7) contains supplementary a subsequent increase in suicide by this method. The pre-
material, which is available to authorized users.
vention of suicide using emerging methods may include
& Ying-Yeh Chen monitoring and regulating online information that provides
ychen@tpech.gov.tw details of these methods as well as encouraging Internet
1
service providers to provide help-seeking information.
Institute of Health Policy and Management, and Department
of Public Health, College of Public Health, National Taiwan
University, Taipei, Taiwan Keywords Charcoal burning  Google search 
2
Hong Kong Jockey Club Centre for Suicide Research and
Newspaper  Internet  Suicide  Media  Taiwan
Prevention, The University of Hong Kong, Hong Kong,
Hong Kong
3
Department of Social Work and Social Administration, Introduction
The University of Hong Kong, Hong Kong, Hong Kong
4
School of Economics, The University of Sydney, Sydney, Suicides from carbon monoxide poisoning by burning
Australia barbecue charcoal in an enclosed space increased dra-
5
Taipei City Psychiatric Center, Taipei City Hospital, Taipei, matically in several East/Southeast Asian countries in the
Taiwan early 2000s [15]. This increase was most prominent in
6
Department of Public Health, Institute of Public Health, Taiwan, where use of the method increased by 65-fold
National Yang-Ming University, Taipei, Taiwan between 1995 and 2011 [5]. The rapid adoption of this
7
Taipei City Psychiatric Center, 309 Songde Road, XinYi method has made curbing its further spread a crucial task in
District, Taipei, Taiwan suicide prevention.

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1452 Soc Psychiatry Psychiatr Epidemiol (2015) 50:14511461

The rapid increase in charcoal-burning suicide is Methods


thought to be related to media glamorization of this method
as a painless, peaceful, and effective way of ending ones Suicide data
life [68]. In a recent interview-based study conducted in
20092010 among people who survived a suicide attempt Data for the weekly counts of suicide (20082011) were
by burning charcoal in Taiwan, approximately 87 % of extracted from Taiwans national death registry. The study
them reported that their choice of method was influenced period was determined by data availabilitystable Inter-
by the media [9]. During the early stage (19982002) of net search trend data for Taiwan became available from
this suicide epidemic in Taiwan, it was estimated that an Google from 2008 (explained in more detail in the below),
increase of one newspaper article reporting charcoal- and at the time of the analysis complete suicide data were
burning suicide was associated with a 16 % increase in available up to 2011. We used the following codes in the
suicide by this method on the following day [8]. However, International Classification of Diseases, 10th revision
the incidence of suicide using this method remained at a (ICD-10), to extract data for suicide: X60X84 (inten-
high level even after the newspaper reporting intensity of tional self-harm) and Y10Y34 (intent undetermined).
charcoal-burning suicide began to decline in 2002 [8], Deaths certified as undetermined intent (i.e. undetermined
suggesting that media channels other than newspapers may deaths) were included because previous findings from
have continued to contribute to the spread of information Western countries [20] and Taiwan [21] all indicate that
regarding the charcoal-burning method. The Internet is one many deaths in this category are likely to be misclassified
media channel that allows the continued access to suicide- suicides. There is no specific code for carbon monoxide
related information after reporting in the traditional press poisoning suicide by charcoal burning in the ICD classi-
has abated. fication system, with suicides by this method being coded
Since the early 2000s, Taiwan has witnessed a rapid under the category X67 (intentional self-poisoning by
increase in Internet use [10]. It has been shown that de- other gases and vapours). Therefore, we used X67 and its
tailed technical information about suicide methods is corresponding code in the undetermined intent category,
readily available on the Internet [11, 12], and searching Y17, to extract data for charcoal-burning suicides. A
online information related to suicide methods appears to be previous study showed that nearly 90 % of deaths re-
common among users with high suicidality [13]. When ceiving the code X67 or Y17 were charcoal-burning sui-
searching charcoal burning on Internet search engines in cides [22]. Sensitivity analyses were conducted based on
Hong Kong, where newspapers reporting style for suicide certified suicides only (i.e., undetermined deaths
stories is similar to that in Taiwan [14], it was found that excluded).
32 % of the first three pages of results were suicide news
published on various newspaper websites and 9 % were Google search data
discussions in online forums [15]. Thus, Internet search
engines provide easy access to detailed suicide method- Data for online searches using terms related to suicide
related information, as well as exposure to the sensational methods were extracted from Google Trends (http://www.
reporting of suicide stories. google.com/trends/), filtering for Taiwan in the period
In the context of media evolution, it is important to 20082011. Google was among the most popular search
investigate whether Internet search is related to the inci- engines in Taiwan during the study period, with a market
dence of suicide. Several recent studies have indicated that share of around 4253 % [23]. The data were weekly
Internet searches using suicide-related terms are associated search volumes on Google in relative figuresthe week
with suicide incidence in the general population [1619]. with the highest number of searches during the study pe-
However, few studies have examined how Internet search riod was assigned a value of 100 and data for other weeks
volume is related to the incidence of suicide using were scaled accordingly. Thus, each one point increase
emerging methods such as charcoal burning [4]. In addi- indicates a 1 % rise in search volume relative to the highest
tion, little is known about whether suicide method-related volume. Data for the absolute volume of searches or higher
Internet search behaviour and newspaper reporting are re- sampling frequency (e.g., daily search volume) were not
lated, or whether each is individually or jointly associated made available from Google. We extracted the data using a
with method-specific suicide incidence. The aim of the range of Chinese terms related to suicide methods such as
current study is to investigate the relationship between charcoal burning, hanging, jumping, and pesticide
Internet searches using terms related to specific suicide ingestionthese were the four most common methods of
methods, the intensity of newspaper reporting of suicides suicide in Taiwan, accounting for 80 % of all suicides in
by different methods, and method-specific suicide inci- 20082011. We used four terms (different expressions of
dence in Taiwan. charcoal burning and charcoal-burning suicide in

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Chinese) to extract Google searches on charcoal-burning In the first set of analyses, we examined whether Google
suicide, and an additional 22 method-specific Chinese search volume was associated with newspaper reporting of
terms for other methods of suicide (see supplementary suicide in the same and preceding weeks. This was con-
electronic material Table 1 for a complete list of these ducted by including Google search volume as the depen-
terms in English and Chinese). For charcoal-burning sui- dent variable and both the contemporaneous and lagged
cide, 23 of the first 29 weeks in 2008 showed zero search (-1 week) variables of newspaper reporting as indepen-
volumes, indicating low related search activities during this dent variables in the regression models. We estimated the
period, and thus we only used data from the 30th week autoregressive Poisson regression model using the com-
onward in the analysis. Our final dataset consisted of mand proc model in SAS.
weekly suicide and Google search records spanning the In the second set of analyses, we examined whether
time period from 27th July 2008 to 31st December 2011 suicide incidence was associated with Google search
(179 weeks in total). volume or newspaper reporting in the same and preceding
weeks. This was conducted by including suicide incidence
Newspaper articles data as the dependent variable, and the contemporaneous and
lagged (-1 week) variables of Google search volume
Newspaper articles on suicide over the same time period and/or newspaper reporting as independent variables in
were extracted from the following electronic Chinese the regression models. We included the suicide count of
newspaper archives: United Daily News Dataset [for the previous week to control for temporal dependence. On
United Daily (UD)], Knowledge Media Winner [for China account of the findings of previous studies which sug-
Times (CT)], and Wisenews [for Apply Daily (AD) and gested that the impact of media reporting on suicide was
Liberty Times (LT)]. These four newspapers are the most most marked in the first 24 weeks [27], we also con-
read national newspapers in Taiwan [24]. UD and CT are ducted a sensitivity analysis adding one more lagged term
deemed traditional newspapers with a history of more than (-2 week) of Google search volume and newspaper re-
50 years in Taiwan [25], and there are certain levels of porting. Since time trends, monthly variations [28],
overlap for the readership of these two newspapers; for unemployment rate, divorce rate [29], and a Taiwanese
example, their readers are more likely to be middle-class celebrity suicide on 13th November 2008 [30] were
elite with a nationalist political orientation (i.e., pro-unifi- shown to be associated with suicide incidence, these
cation with mainland China) [26]. By contrast, LT has a variables were simultaneously adjusted for in all models.
political stance of pro-independence and generally stands For all models considered, time trend was assumed to be
for the working class [25, 26]. AD is originally from Hong linear in time, and monthly variation was captured by 11
Kong and has come to Taiwan since 2003; it is commonly dummies that indicate the specific month for each
seen as a tabloid newspaper. Regarding reader character- observation.
istics, except UD, the three other newspapers (CT, LT, and Three models were estimated to investigate the asso-
AD) tend to have more male readers than female readers ciations between suicide incidence and (a) Google search
[26]. The UD readers are also more likely to be in the volume only (Model 1), (b) newspaper reporting only
middle-aged group (3059 years) than those of other three (Model 2), and (c) both Google search volume and news-
newspapers [26]. paper reporting jointly (Model 3). Incidence rate ratios
To extract data for newspaper reporting of suicide, we (IRRs) for suicide were estimated to study the effect on
first identified newspaper articles with a title that contains suicide incidence per 10 % increase in Google search ac-
Chinese terms related to suicide, e.g. suicide, charcoal tivity or per one newspaper article increase. By comparing
burning, and hanging. We excluded editorials, com- results between Models 1 and 3 we would be able to ex-
mentaries, fictional stories, and articles related to suicide amine a potential mediating role of newspaper reporting on
terrorism or the psycho-education of suicide. Articles were the association between suicide incidence and Google
then inspected individually to separate reports on charcoal- search volume. It was shown that media coverage can in-
burning suicides from those on suicides by other methods. fluence both the incidence of suicide [3133] and Google
Finally, data for the weekly number of articles from each of search volume [34, 35].
the four newspapers were compiled. The four newspapers were modelled individually instead
of in aggregate due to the following reasons. First, it was
Statistical analysis shown that Taiwans newspapers demonstrated different
trends in suicide reporting and exhibited various asso-
We first examined (a) the association between Google ciations with suicide incidence [36, 37]; for example, sui-
search volume and newspaper reporting, and then (b) their cide incidence on the following day was associated with
associations with suicide incidence. the number of suicide articles in only one (UD), but not in

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the other two (CT and AD) newspapers [37]. Second, as Results
presented later in Results, the four newspapers showed
very different trends in suicide reporting over the study Figure 1a shows the trends in weekly suicide incidence in
period (Fig. 1) and thus combining their data would ob- Taiwan during the study period (27th of July 2008the 31st
scure these important differences and likely miss their re- of December 2011).There were 14920 suicides (68 %
spective, potential associations with suicide trends [36, 37]. male; 42 % \45 years old; 27 % charcoal-burning suicide)
Third, the market share and readership of the four news- over this period. On average, there were 23 [standard de-
papers varied considerably [24, 26], making it difficult to viation (SD) = 7] charcoal-burning suicides and 61
combine their data by simply aggregating the number of (SD = 10) non-charcoal-burning suicides per week.
suicide articles. Charcoal-burning suicide showed some abatement over the
We conducted analyses separately for charcoal-burning study period, while the trends in non-charcoal-burning
suicide and non-charcoal-burning suicide. In addition, we suicide remained relatively stablethe number of deaths
examined differences in the Google search effect between per week fell from 25 (SD = 7) in 2008 to 18 (SD = 6) in
males and females, as well as between younger (age 2011 for charcoal-burning suicide and from 61 (SD = 8) in
\45 years) and older (age C45 years) people by including 2008 to 58 (SD = 11) in 2011 for non-charcoal-burning
appropriate interaction terms in the models. suicide.

Fig. 1 Time trends in weekly incidence of a suicide, b Google search volume, and cf articles reporting suicide in four major newspapers in
Taiwan, 27th July 200831st December 2011

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Figure 1b shows the trends in weekly search volume terms related to charcoal-burning suicide was positively
using terms related to suicide methods on Google, and associated with the number of articles reporting suicide by
Figs. 1cf show the trends in the weekly number of articles this method in UD and CT in the preceding week. By
reporting suicide in each of the four major newspapers in contrast, the number of suicide news articles reported in
Taiwan (UD, CT, AD, and LT). The level of search volume AD in the preceding week was negatively associated with
shown in Fig. 1b could not be directly compared between Google searches. For non-charcoal-burning suicide, Goo-
charcoal-burning and non-charcoal-burning suicide, as gle search was positively associated with newspaper re-
their data were scaled differently according to different porting of AD and LT in the same week.
levels of the highest number of searches over the data
extraction period. No obvious trend was observed for Associations of suicide with Google search
charcoal-burning or non-charcoal-burning suicide, while and newspaper reporting
both showed substantial week by week variations in Goo-
gle search volume. The peak for charcoal-burning suicide Table 2 shows the associations of trends in suicide with
occurred in the week between 18th and 24th April 2010 Google search volume only (Model 1), newspaper report-
when there was extensive media coverage of a homicide ing only (Model 2), and both Google search volume and
suicide by charcoal burning. During the 179-week study newspaper reporting in the fully adjusted models (Model
period, the mean weekly number of newspaper articles 3). The incidence of charcoal-burning suicide was
reporting suicide was highest for UD [11.6 (SD = 3.7)], positively associated with Google search volumes in the
followed by LT [10.4 (SD = 4.3)], AD [7.4 (SD = 3.1)], same week and in the preceding week (Model 1), and it
and CT [6.6 (SD = 3.4)]. Mean weekly number of news- was also positively associated with the reporting of char-
paper articles ranged between 1.4 (CT) and 2.8 (UD) for coal-burning suicide in the same week for one newspaper,
charcoal-burning suicide, and between 5.3 (CT) and 8.8 UD (Model 2). These associations were still observed in
(UD) for non-charcoal-burning suicide. the model including both Google search volume and
newspaper reporting of charcoal-burning suicide (Model
Associations of Google search with newspaper 3). Every 10 % increase in Google search volume in the
reporting same week and in the previous week was associated with a
4.3 % [95 % confidence interval (CI) 1.17.6 %] and a
Table 1 shows the association between Google search 3.8 % (CI 0.47.2 %) increase in the incidence of charcoal-
volume trends and newspaper reporting of suicide in the burning suicide, respectively, while an additional article in
same and preceding week. Google search volume using the United Daily was associated with a 3.6 % (CI

Table 1 The association of Variable Coefficient 95 % CI p value


trends in Google search with
newspaper reporting Google search using terms related to charcoal-burning suicide
UD (the same week) 0.009 -0.008, 0.026 0.30
UD (the previous week) 0.023 0.005, 0.040 0.012
CT (the same week) -0.007 -0.032, 0.017 0.55
CT (the previous week) 0.029 0.005, 0.053 0.019
AD (the same week) 0.005 -0.019, 0.030 0.66
AD (the previous week) -0.026 -0.049, -0.002 0.036
LT (the same week) 0.011 -0.008, 0.030 0.27
LT (the previous week) -0.013 -0.033, 0.007 0.21
Google search using terms related to suicide methods other than charcoal burning
CT (the same week) -0.004 -0.018, 0.010 0.083
CT (the previous week) 0.005 -0.008, 0.019 0.66
AD (the same week) 0.018 0.003, 0.033 0.56
AD (the previous week) -0.012 -0.027, 0.003 0.43
LT (the same week) 0.013 0.003, 0.023 0.017
LT (the previous week) 0.004 -0.007, 0.014 0.13
Time trend and month effect were all controlled in the models
UD United Daily, CT China Times, AD Apply Daily; LT Liberty Times

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Table 2 The association of trends in suicide incidence with Google search and/or newspaper reporting of suicide
Variable Model 1 Model 2 Model 3
a a
IRR 95 % CI p IRR 95 % CI p IRRa 95 % CI p

Charcoal-burning suicide
Google search (the same week) 1.056 1.025, 1.089 0.001 1.043 1.011, 1.076 0.008
Google search (the previous week) 1.039 1.006, 1.073 0.022 1.038 1.004, 1.072 0.027
UD (the same week) 1.038 1.017, 1.059 \0.001 1.036 1.015, 1.058 0.001
UD (the previous week) 1.004 0.982, 1.027 0.70 0.998 0.975, 1.021 0.84
CT (the same week) 1.027 0.997, 1.058 0.083 1.024 0.994, 1.056 0.12
CT (the previous week) 1.023 0.992, 1.055 0.15 1.021 0.990, 1.053 0.19
AD (the same week) 0.995 0.966, 1.025 0.75 0.994 0.965, 1.025 0.72
AD (the previous week) 0.995 0.966, 1.024 0.73 0.999 0.970, 1.029 0.96
LT (the same week) 1.000 0.978, 1.023 0.98 1.000 0.977, 1.023 1.00
LT (the previous week) 0.995 0.972, 1.019 0.66 0.994 0.971, 1.018 0.65
Non-charcoal-burning suicide
Google search (the same week) 0.986 0.960, 1.012 0.29 0.983 0.957, 1.011 0.23
Google search (the previous week) 1.005 0.981, 1.030 0.68 1.004 0.978, 1.030 0.76
UD (the same week) 1.003 0.995, 1.011 0.50 1.003 0.995, 1.011 0.48
UD (the previous week) 0.996 0.988, 1.004 0.27 0.995 0.987, 1.003 0.25
CT (the same week) 1.005 0.995, 1.015 0.32 1.005 0.995, 1.015 0.35
CT (the previous week) 0.994 0.985, 1.004 0.23 0.994 0.985, 1.004 0.25
AD (the same week) 0.996 0.986, 1.006 0.43 0.997 0.987, 1.007 0.56
AD (the previous week) 1.012 1.002, 1.022 0.02 1.011 1.001, 1.021 0.030
LT (the same week) 1.003 0.996, 1.010 0.35 1.004 0.997, 1.011 0.26
LT (the previous week) 0.996 0.989, 1.003 0.28 0.996 0.989, 1.003 0.27
Time trend, month effect, unemployment rate, divorce rate, and a celebrity suicide in November 2008 were all controlled in the models
UD United Daily, CT China Times, AD Apply Daily; LT Liberty Times
a
Incidence rate ratio for suicide (per 10 % increase in Google search volume or per one-article increase in newspaper reporting)

1.55.8 %) increase in charcoal-burning suicide in the analysis using only certified suicides showed very similar
same week. By contrast, the trend in non-charcoal-burning findings (supplementary electronic material Table 2).
suicide was not associated with Google search volume, Moreover, by including the data before the preceding week
while it was associated with ADs suicide reporting in the (i.e., -2 weeks), we did not find any statistically sig-
preceding week. nificant association of suicide incidence with Google
There was statistical evidence for sex difference in the search volume or newspaper article counts lagged by
association of charcoal-burning suicide with Google search 2 weeks (supplementary electronic material Table 3).
volume in the same week, (p for interaction = 0.008), but
only limited evidence in the preceding week (p for inter-
action = 0.12). Sex-specific analyses revealed stronger Discussion
associations between Google search volume and charcoal-
burning suicide among females than males, particularly in Main findings
the same week association (Table 3). In the fully adjusted
model (Model 3), every 10 % increase in Google search Our analysis shows that an increase in Google search
volume was associated with an average of 1.7 % (CI -2.0 volume using terms related to charcoal-burning suicide was
to 5.5 %) and 11.3 % (CI 5.118.0 %) rise in suicide for associated with the incidence of suicide by this method in
males and females in the same week, respectively. There the same and following week, even after adjusting for
was no statistical evidence for age differences (p for in- newspaper reporting of suicide. The association between
teraction [0.5). Google search volume and suicide in the same week could
To ensure the robustness of the above findings, we be because an increase in suicide reporting in the media,
carried out a number of sensitivity analyses. A sensitivity e.g. TV and newspapers, led to increased interest and

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Table 3 The association of trends in male and female charcoal-burning suicide incidence with Google search and/or newspaper reporting of
suicide
Variable Model 1 Model 2 Model 3
a a
IRR 95 % CI p IRR 95 % CI p IRRa 95 % CI p

Males
Google search (the same week) 1.030 0.993, 1.068 0.12 1.017 0.980, 1.055 0.38
Google search (the previous week) 1.032 0.994, 1.072 0.10 1.027 0.988, 1.067 0.17
UD (the same week) 1.040 1.016, 1.066 0.001 1.040 1.015, 1.065 0.002
UD (the previous week) 1.006 0.980, 1.033 0.67 1.003 0.976, 1.030 0.85
CT (the same week) 1.024 0.989, 1.060 0.19 1.022 0.986, 1.058 0.23
CT (the previous week) 1.020 0.984, 1.058) 0.28 1.019 0.983, 1.057 0.31
AD (the same week) 0.991 0.956, 1.026 0.61 0.991 0.956, 1.026 0.60
AD (the previous week) 1.001 0.967, 1.036 0.96 1.002 0.968, 1.037 0.90
LT (the same week) 1.007 0.981, 1.035 0.59 1.008 0.981, 1.035 0.56
LT (the previous week) 0.992 0.965, 1.020 0.56 0.992 0.964, 1.020 0.55
Females
Google search (the same week) 1.121 1.063, 1.182 \0.001 1.113 1.051, 1.180 \0.001
Google search (the previous week) 1.073 1.011, 1.138 0.020 1.067 1.004, 1.133 0.037
UD (the same week) 1.033 0.993, 1.074 0.10 1.028 0.988, 1.069 0.17
UD (the previous week) 1.011 0.970, 1.054 0.60 0.993 0.952, 1.037 0.76
CT (the same week) 1.036 0.979, 1.096 0.22 1.033 0.976, 1.094 0.26
CT (the previous week) 1.035 0.976, 1.097 0.25 1.027 0.968, 1.089 0.38
AD (the same week) 1.017 0.961, 1.076 0.56 1.013 0.957, 1.072 0.66
AD (the previous week) 0.980 0.927, 1.036 0.47 0.992 0.938, 1.049 0.78
LT (the same week) 0.978 0.936, 1.021 0.31 0.974 0.932, 1.018 0.24
LT (the previous week) 1.003 0.959, 1.049 0.89 1.004 0.959, 1.051 0.87
UD United Daily, CT China Times, AD Apply Daily; LT Liberty Times
Time trend, month effect, unemployment rate, divorce rate, and a celebrity suicide in November 2008 were all controlled in the models
a
Incidence rate ratio for suicide (per 10 % increase in Google search volume or per one-article increase in newspaper reporting)

online searches among Internet users, although we did and news reporting in traditional media (newspapers). In
adjust for newspaper reporting in the analysis. By contrast, contrast, most previous studies only focused on the asso-
the association between Google search volume and char- ciation of suicide with either Internet search or newspaper
coal-burning suicide incidence in the following week reporting. One Japanese study has examined the asso-
suggests that some people who searched, read, or studied ciation between trends in suicide by inhaling hydrogen
this method online may later die by employing this method. sulphide and both Internet search and newspaper reporting
Such associations were not found for non-charcoal-burning [38], but that study did not investigate whether the asso-
suicide. ciation was specific to this new suicide method.
We only found an association between the newspaper There are several limitations to our study. First, this is
reporting of suicide and charcoal-burning suicide in the an observational study and the association shown cannot be
same week for one (United Daily) out of the four news- viewed as evidence confirming that people had searched
papers studied. The association might be related to the charcoal-burning suicide online before killing themselves
United Dailys comparatively high-intensity reporting of using this method. However, one recent study from the UK
suicide stories. suggested that some had done so [39]. Second, our analysis
was limited to weekly Internet search data which provide
Strengths and limitations less temporal resolution than daily data. However, previous
studies assessing the correlation between Internet search
To our knowledge, this study is among the first investiga- trends and suicide generally used monthly data [1618, 40,
tions which have studied the association between method- 41], and the use of weekly data in our study is an important
specific suicide incidence and trends in both Internet search improvement over these previous studies, allowing us to

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specify whether the increase in suicide occurred before, [3, 4, 47]. However, in contrast to our findings, increased
during, or after the Internet search on a weekly scale. Still, Internet searches and news reports were not found to be
a contemporaneous association in the same week is limited associated with an increase in charcoal-burning suicides
in that it does not provide evidence of a detailed temporal during any of the other time periods in 20072011 [4]. This
sequence between the exposure and outcome. Third, the may be due to the fact that charcoal-burning suicide still
association found in the time series data may be con- accounted for a relatively small proportion of all suicides
founded by factors not included in the analysis, e.g. (0.87 % in 20072011) in South Korea [5], compared to
changes in levels of mental health [42], which could be 2428 % in Taiwan over the same time period [5], and
related to both suicide incidence and Internet search be- therefore news reports of non-celebrity charcoal-burning
haviours; however, we have adjusted for a number of po- suicides and related Internet searches, as well as their im-
tential confounding variables in our analysis. Finally, only pact on incidence of suicide using this method, were lim-
data from Google were used, as they are the only com- ited in South Korea.
prehensive Internet search data available to us. While By contrast, our study reveals a consistent association
Google is among the most commonly used search engines between Google search volume and an increased incidence
in Taiwan (market share 4253 % [23] ), a survey in 2009 of charcoal-burning suicide throughout 20082011. How-
has suggested that its users are more likely to be male and ever, we do not observe the same association for non-
students aged 2029 years compared with users of other charcoal-burning suicide. Our results suggest that, in Tai-
search engines [43]. It is not known whether the differences wan, online searching could be an important way for some
in the characteristics of users of different search engines at-risk individuals to learn about the charcoal-burning
would have affected our results [44, 45]. Furthermore, the method, which is still a relatively novel and technically
characteristics of Google users may limit our analyses of intensive method compared to other conventional suicide
sex and age differences in the associations of suicide with methods such as hanging. This is in line with findings from
Internet searches. previous person-based studies indicating that some suicidal
individuals deliberately search online information for sui-
Comparison with previous findings cide methods when planning their attempts [13, 4851].
One recent study in England shows that some people who
Our data showed a generally positive association between killed themselves by burning charcoal obtain information
newspaper coverage of suicide stories and Internet searches about this method from the Internet [39].
using suicide-related words, although the association var- For charcoal-burning suicide, news reporting in only one
ied by newspaper, suicide method, and temporal relation- newspaper (UD) was associated with suicide incidence
ship (same week or lagged by 1 week associations), and a using this method. This finding is in keeping with that from
negative association was found between suicide articles of a previous Taiwanese study which examined newspaper
one newspaper and Google searches. This suggests that reporting and (all-method) suicide incidence during
media coverage of suicide could be followed by a rise in 20022005 [36]. That study showed that while suicide in-
interest in suicide-related information amongst Internet cidence was associated with the reporting intensity of
users, indicated by the increase in Internet searches. This is suicide stories in UD, no association was detected between
consistent with previous research findings from other the suicide reporting in two other Taiwanese newspapers
countries that media reporting of suicide can influence (CT and AD) and suicide incidence. The difference in
Internet searches of suicide-related information [34, 35, reader characteristics could be a potential contributing
46]. Such associations should be taken into account and factor to the observed pattern [36]. For example, the pro-
controlled for when investigating the link between suicide portion of middle-aged group (aged 3059 years) was
incidence and Internet searches. highest among UD readers compared to those of other three
Although several previous studies have demonstrated an major newspapers (CT, LT, and AD) [26], and this age
association between trends in Internet search and suicide group happened to be the group with the greatest increases
incidence [1618, 40, 41], they did not investigate method- in rates of overall suicide and charcoal-burning suicide in
specific associations as in the present study. A recent time Taiwan [44, 52]. In the present study, we did not analyse
trend analysis conducted in South Korea between 2007 and the content and length of the news articles, and thus the
2011 found an increase in charcoal-burning suicides fol- possibility that differences in reporting styles by newspa-
lowing a surge in Internet searches and news reports of this pers may lead to different associations could not be ruled
method in September 2008 [4]. During that time, the South out.
Korean media widely covered the charcoal-burning suicide The finding that the reporting of non-charcoal-burning
of a Korean celebrity, thus bringing this novel suicide suicide in the Apple Daily (AD) was related to the inci-
method to the forefront of the public eye for the first time dence of non-charcoal-burning suicide in the following

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Soc Psychiatry Psychiatr Epidemiol (2015) 50:14511461 1459

week contrasts with previous research findings [36]. Pre- prevention [59, 60]. Meanwhile, the role of the Internet
vious studies using data before 2005 did not detect any may be double-edged [61, 62]on one hand, it may
impact of ADs reporting [36]. Our research findings sug- provide detailed information on novel suicide methods
gest that the influence of AD may have increased in recent that may result in adverse consequences among vulnerable
years. This coupled with the newspapers high circulation people; on the other hand, it may link Internet users to
in Taiwan makes its suicide reporting worthy of continued support and health-care information [12, 13, 63]. Internet
surveillance. Empirical evidence from several countries, regulations for pro-suicide forums/websites should be
such as Austria, Australia, and Hong Kong, has shown that considered as a component of suicide prevention strate-
the enforcement of media guidelines for reporting suicides gies. Legislative approach to restricting or regulating pro-
may improve the quality of media reporting and prevent suicide sites, as has been piloted in Australia, is a potential
imitative suicides [5355]. policy option [64].
Prior studies tend to suggest that the relationship be- In addition, proactive engagement with online service
tween Internet search volume and suicide is stronger in providers is also worth consideration. For example, in 2010
younger populations than in older age groups [1618]. Our Google began displaying the contact information of Na-
data, however, did not indicate significant interaction by tional Suicide Prevention Lifeline by default whenever
age. Several possible factors related to high fatality of anyone in the US searched suicide-related topics [65]. This
suicide among the elderly may contribute to no significant feature was later extended to the UK, Ireland, Taiwan, and
resultmore medical co-morbidities or higher intention to Hong Kong, where helpline websites (Samaritans web-
die may lead to a higher fatality rate in older suicide at- sitehttp://www.samaritans.org/ for UK and Ireland;
tempters than their younger counterparts when using the Lifeline websitehttp://www.life1995.org.tw/ and www.
same suicide method, even though the association between sps.org.hk for Taiwan and Hong Kong, respectively) are
suicide incidence and Internet search may be actually displayed when Google receives suicide-related queries.
stronger in the younger than the older groups. One recent This default would increase the possibility that suicidal
study from Taiwan showed that case fatality increased with individuals are directed to suicide prevention services. Its
age across suicide methods, including charcoal burning effectiveness is worth further evaluation.
[56].
The finding that the association between Internet search Acknowledgments SSC was supported by the Chiang Ching-kuo
Foundation, Taiwan (Grant number RG014-P-12). PSFY was sup-
volume and charcoal-burning suicide incidence was stron- ported by a grant from the University of Hong Kong (HKU
ger in females than in males was unexpected, particularly in 7003-SPPR-12). YYC was supported by a grant from Ministry of
light of the similar Internet use prevalence observed for Science and Technology (Grant number MOST 103-2314-B-532-
males and females (Broadbandmale: 73.9 %, female: 003-MY2) and a grant from the Department of Health, Taipei City
Government (Grant number 10401-62-011).
70.4 %; wirelessmale: 48.2 %, female: 45.1 %) [57].
However, our findings are in agreement with a recent study Conflict of interest On behalf of all authors, the corresponding
that emphasized a marked diffusion of charcoal-burning author states that there is no conflict of interest.
suicide from the Taiwanese male population to the female
population in recent years [58]. Females may consider
charcoal burning an attractive method that does not disfig-
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