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They call it the “choking game,” but it’s deadly serious. Experts estimate that 5% to 11% of teens have tried it, and a new study published Monday in the journal Pediatrics reports that kids who see this as a way of getting high are also likely to engage in other types of risky behavior, such as drug abuse and sex.

Here’s how the study’s authors, from the Centers for Disease Control and Prevention’s Division of Unintentional Injury Prevention and the Oregon Health Authority’s Public Health Division, describe the choking game:

“The choking game refers to an activity where pressure is applied to the neck/carotid artery to limit oxygen and blood flow; once the pressure is released, a ‘high’ or euphoric feeling might be achieved as blood and oxygen rush back to the brain. … Participation in this activity can lead to serious injury or death.”

The choking game is also known as “knock out,” “black out,” “space monkey,” “flatlining” and “the fainting game.” As my colleague Amina Khan wrote in 2009, players – mostly teens – use “belts, neckties, other types of binding – or a friend’s helping hands” to cut off the supply of oxygen.

At least 82 children between the ages of 6 and 19 are known to have died while playing the choking game, according to the CDC, although the true toll is probably higher because there’s no reliable system for counting such deaths. Even when it’s not fatal, it can lead to coma or seizures; kids who fall while playing can get concussions or broken bones.

In the new study, researchers used data collected in 2009 as part of the Oregon Healthy Teens survey to get a sense of how widespread the choking game was among eighth graders. They found that 22% of the students had heard of someone playing it and 6.1% had done so themselves. Participation rates were the same for boys and girls.

Among those who had played, 64% had tried it more than once and 27% had done so more than five times. Students who were identified as Pacific Islanders were about five times more likely than white students to say they had played the choking game. Also, among boys, black students were more than three times more likely than whites to have tried it.

In further analysis, the researchers found that players were more likely than non-players to use drugs, be sexually active, have poor mental health, have been exposed to violence, be involved in gambling and to have poor nutrition. Looked at another way, the researchers said that students who had ever had sex and had used drugs in the last 30 days were at increased risk for participating in the choking game.

The researchers also looked at 11th graders and found that one-third had heard of someone playing the choking game; 7.6% said they had played it themselves and 1.7% said they had helped someone else do it. The 7.6% participation rate was considered statistically equivalent to the 6.1% rate among eighth graders, making this unusual among “youth risk behaviors” because prevalence did not increase with age.

Despite media reports that “high-achieving, low-risk-taking youth” are more likely to try the choking game, the data from Oregon indicate that’s not true, according to the study.

“Clear, youth-friendly messages about the possible consequences of this activity are warranted,” the researchers wrote. But they also acknowledged that “little is understood about effective choking game prevention messaging or how best to screen for this behavior.” At a minimum, pediatricians should watch for signs of bruises or other marks around the throat, they wrote.

The full study is behind a pay wall, but you can read a summary here.

For more on the choking game, check out this backgrounder from the CDC.

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