title: Prevalence and associated harm of engagement in self-asphyxial behaviours ('choking game') in young people: a systematic review.
abstract: OBJECTIVE
  To assess the prevalence of engagement in self-asphyxial (risk-taking) behaviour (SAB) ('choking game') and associated morbidity and mortality in children and young people up to age 20.
  
  
  METHODS
  Systematic literature review.
  
  
  METHODS
  Electronic database search of MEDLINE, Embase, PsycINFO, CINAHL, PubMed, Web of Science Core Collection, BIOSIS citation index and the Cochrane register with no language or date limits applied. References of key papers were reviewed, and experts were contacted to identify additional relevant papers.
  
  
  METHODS
  Systematic reviews, cross-sectional, cohort and case-control studies, and case reports examining SAB with regard to individuals aged 0-20 years, without explicitly stated autoerotic, suicidal or self-harm intentions were included.
  
  
  RESULTS
  Thirty-six relevant studies were identified, and SAB was reported in 10 countries. In North America, France and Colombia, awareness of SAB ranged from 36% to 91% across studies/settings, and the median lifetime prevalence of engagement in SAB was 7.4%. Six studies identified the potential for SAB to be associated with engagement in other risk behaviours. Ninety-nine fatal cases were reported. Of the 24 cases described in detail, most occurred when individuals engaged in SAB alone and used a ligature.
  
  
  CONCLUSIONS
  The current evidence on SAB among young people is limited, and stems predominantly from North America and France. Awareness of SAB among young people is high, and engagement varies by setting. Further research is needed to understand the level of risk and harm associated with SAB, and to determine the appropriate public health response.
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: H
authors.initials: H
authors.lastname: Busse
authors.affiliation: Independent Public Health Doctor.
authors.forename: T
authors.initials: T
authors.lastname: Harrop
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: D
authors.identifier: http://orcid.org/0000-0002-0829-6470
authors.initials: D
authors.lastname: Gunnell
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: R
authors.identifier: http://orcid.org/0000-0002-5446-8077
authors.initials: R
authors.lastname: Kipping
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior; D000402:Airway Obstruction / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D015995:Prevalence; D012307:Risk Factors; D012309:Risk-Taking; D016728:Self-Injurious Behavior / Q000453:epidemiology* / Q000401:mortality; D055815:Young Adult
keywords: Adolescent Health; Injury Prevention; Paediatric Practice; Public Health; School Health