OBJECTIVE: The purpose of this study was to compare characteristics of youth who participate in the choking game alone versus those who participate in a group. METHODS: Lifetime prevalence estimates were obtained from the 2011 (n = 5682) and 2013 (n = 15 150) Oregon Healthy Teens survey. The 2011 and 2013 data sets were merged (N = 20 832) to compare youth who participate alone versus those who participate in a group in the choking game. Multivariate modeling was conducted to examine individual characteristics of young people who engaged in the choking game alone versus those who engaged in the game in a group. RESULTS: In 2011, 3.8% of eighth-grade participants reported a lifetime prevalence of choking game participation; 3.7% reported lifetime prevalence of participation in 2013. In the merged 2011/2013 data set, 17.6% (n = 93) of choking game participants indicated that they had participated alone. Compared with those who reported participating in a group, youth who participated alone had significantly higher rates of suicide contemplation (odds ratio: 4.58; P < .001) and poor mental health (odds ratio: 2.13; P < .05). CONCLUSIONS: Youth who participate alone in the choking game are a particularly high risk group, exhibiting substantially higher rates of suicidal ideation and poorer mental health compared with youth who participate in the choking game in a group. Adolescent health care providers should be aware of these associations, assess whether prevention messaging is appropriate, and be prepared to explain the high risks of morbidity and mortality associated with participation.