The systematic review by Busse et al1 draws attention to the prevalence and associated harm of engagement in self-asphyxial behaviours (SAB) (‘choking game’) in young people. SAB have evolved from the largely benign playground ‘games’ based on inducing fainting familiar a generation ago, to become a form of social or learned behaviour with significant risk of fatality because a subgroup of participants engage in solitary and even competitive practices involving strangulation.2 The potential for death or serious injury exists in part because most children and youth do not associate SAB with risk of injury or any long-term harm in spite of widespread awareness of the practice and significant prevalence of engagement, but also because self-asphyxial activities are not ‘on the radar’ of those in a position to counsel and guide in the context of risk-taking behaviours in general.

Consequently, to some, the research summarised in this review will provide new insight on the frequency of participation, widespread distribution and potential for adverse outcome from participation in this risk-taking behaviour. It is evident that most parents, healthcare professionals and teachers are unaware that 36%–91% of school-age children are reported to know about SAB. The mean lifetime prevalence of engagement is 7.4% and that fatalities from SAB have been documented in 10 …