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Reported association of air pollution and suicide rate could be confounded Afshari, R. Feb 28, 2017

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LETTER TO THE EDITOR Open AccessReported association of air pollution andsuicide rate could be confoundedR. Afshari1,2AbstractA statistical association between ambient air pollution and suicide mortality has been recently reported inEnvironmental Health, which seems not to be scientifically supported by their data.In this article, very low (unrealistic) suicide rate is reported, which is subjected to selection bias. Their justification isalso flawed as high exposure to ambient air pollution in rural areas is lower as compared to urban residents.Weekends, holidays, time of death … are also both air pollution and suicide rate related. Reported statisticalassociation of air pollution and suicide in this study is heavily confound.Please see article under discussion: https://ehjournal.biomedcentral.com/articles/10.1186/s12940-016-0177-1.Keywords: Air pollution, Suicide, Underreporting, Selection biasDear Editor,I have read with interest your recent publication onassociation between ambient air pollution and suicidemortality [1]. Their conclusion does not seem to be epi-demiologically supported.The total rate of suicide in East Asian countries such asJapan and South Korea is relatively higher (19 × 10−5 and17 × 10−5) than the rest of the world [2]. China, however,reports lower rates.According to the Bulletin of the World HealthOrganization, suicide in China accounts for about aquarter of all suicides worldwide in the past decades [3].High rates have also been reported in the recent yearsincluding 14.7 to 9.1 × 10−5 2006-2012 [4], 46 × 10−5 [5],and 34.5 × 10−5 (elderly suicide rate) in this country [6].Authors reported a total of 1 550 registered suicidedeaths in Guangzhou with a population of 7.7 millionpermanent residents (i.e. 60.8% of population ofGuangzhou) between 2003 and 2012 [1]. Taking thesevalues, the suicide rate would be 2.2 × 10−5, which is farlower than the lowest reported rates and subjected tounderreporting. The extent of which seems to be largeenough to reasonably question their findings.The rate of suicide underreporting for different sexes, agegroups, sexuality tendencies and types of suicide are diverse[7–10], which authors superficially mentioned. In additionto subpopulations, there are systematic reasons for under-reporting including low accuracy in determining the under-lying causes of deaths [11], inaccurate collection andcoding (misclassifying of suicides as injuries) that are prob-lematic for data stakeholders [12], stigma [13] and highstandards of proof [12]. Majority of these reasons, for ex-ample, are different for urban population with high expos-ure to ambient air pollution and rural residents in which airpollution is low. As a result under reporting in this study issubjected to selection bias. Weekends, holidays, time ofdeath … are also both air pollution and suicide rate related,and confound their findings to a further extent.Reported association between air pollution and sui-cide is at best questionable. Findings should be treatedwith caution.AcknowledgementsN/A.Availability of data and materialData sharing not applicable to this article as no datasets were “generated”during the current study. However, all analysed data and material reported inthis letter to editor are available. Original data that are being argued againstare already published in an article in Environmental Health “Lin, G.Z., et al.,The impact of ambient air pollution on suicide mortality: a case-crossoverstudy in Guangzhou, China. Environ Health, 2016. 15(1): p. 90”.Correspondence: Reza.Afshari@bccdc.ca; http://www.bccdc.ca1BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z4R4, Canada2Occupational and Environmental Health Division, School of Population andPublic Health, University of British Columbia, Vancouver, Canada© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Afshari Environmental Health  (2017) 16:16 DOI 10.1186/s12940-017-0219-3Authors’ contributionsRA wrote the first draft of the manuscript. He did not receive an honorarium,grant, or other form of payment to produce the manuscript.Competing interestsThe author declares that he has no competing interests.Consent for publicationN/A. In a personal level, I give my consent for publication of this letter.Received: 30 December 2016 Accepted: 14 February 2017References1. Lin GZ, et al. The impact of ambient air pollution on suicide mortality: acase-crossover study in Guangzhou, China. Environ Health. 2016;15(1):90.2. Jeon SY, Reither EN, Masters RK. A population-based analysis of increasingrates of suicide mortality in Japan and South Korea, 1985-2010. BMC PublicHealth. 2016;16:356.3. Bulletin of the World Health Organization. Women and suicide in ruralChina. http://www.who.int/bulletin/volumes/87/12/09-011209/en/. Accessed20 Oct 2016.4. Liu S, et al. Spatiotemporal variation and social determinants of suicide inChina, 2006-2012: findings from a nationally representative mortalitysurveillance system. Psychol Med. 2015;45(15):3259–68.5. Sun J, et al. Incidence and fatality of serious suicide attempts in apredominantly rural population in Shandong, China: a public healthsurveillance study. BMJ Open. 2015;5(2):e006762.6. Zhong BL, Chiu HF, Conwell Y. Rates and characteristics of elderly suicide inChina, 2013-14. J Affect Disord. 2016;206:273–9.7. Speechley M, Stavraky KM. The adequacy of suicide statistics for use inepidemiology and public health. Can J Public Health. 1991;82(1):38–42.8. Alves MA, Cadete MM. Suicide attempts among children and adolescents:partial or total injury? Cien Saude Colet. 2015;20(1):75–84.9. Deuter K, et al. Suicide in older people: revisioning new approaches. Int JMent Health Nurs. 2016;25(2):144–50.10. Hottes TS, et al. Lifetime prevalence of suicide attempts among sexualminority adults by study sampling strategies: a systematic review and meta-analysis. Am J Public Health. 2016;106(5):e1–12.11. Sun J, et al. Suicide rates in Shandong, China, 1991-2010: rapid decrease inrural rates and steady increase in male-female ratio. J Affect Disord. 2013;146(3):361–8.12. De Leo D, et al. Achieving standardised reporting of suicide in Australia:rationale and program for change. Med J Aust. 2010;192(8):452–6.13. Auger N, et al. Suicide in Canada: impact of injuries with undeterminedintent on regional rankings. Inj Prev. 2016;22(1):76–8.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Afshari Environmental Health  (2017) 16:16 Page 2 of 2

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