Exposure to natural altitude using the "live high-train low" method improves athletic endurance performance at sea level by 1-2%. This method can also be employed with hypoxic devices that simulate altitude, but there is limited and conflicting research on their efficacy. Consequently, three studies were undertaken to investigate changes in sea level performance of endurance runners following exposure to altitude simulated with hypoxic tents. The device was chosen because of its potential for incorporation into the athlete's routine. In Study 1, 10 runners received altitude simulated with hypoxic tents (~9 h overnight at 2500-3500 m) and trained at sea level, while 10 runners in the control group performed usual training. Athletes in both groups performed a lactate-threshold test, but only the altitude group performed a run to exhaustion. The effect on 4-mM lactate speed was unclear, owing to poor reliability of this measure. There was a 16% increase in time to exhaustion in the hypoxic conditioning group, equivalent to a 1.9% (90% likely limits, ±1.4%) increase in speed in a time trial. Effects on performance were not apparent four and eight weeks after use of the tents. To improve precision of the effect of the tents and to determine the effects on performance of different durations, a further controlled trial was performed. A reliability study (Study 2) was first conducted to investigate the potential for runs to exhaustion to provide reliable measures of performance. Eight runners performed a test consisting of three runs to exhaustion lasting ~2, ~4 and ~8 min on six occasions over 14 wk. The critical power and log-log models were used to provide factors for converting variability in time to exhaustion into variability in equivalent time-trial time. Variabilities in time to exhaustion expressed as coefficients of variation for predicted 800-3000 m timetrial times were ~1-3%. A crossover study (Study 3) was then conducted in which 11 athletes performed usual (control) training and usual training with altitude exposure by using tents for 25 ± 3 days (mean ± SD) for 8.1 ± 0.6 h.d-1, progressing from a simulated altitude of 2500 m to 3500 m above sea level. Washout period between control and altitude treatments was four weeks. Performance was assessed with treadmill runs to exhaustion as in Study 2. Improvements in mean predicted times (altitude-control) for standard competition distances of 800, 1500 and 3000 m derived from the runs to exhaustion were 1.0% (±1.3%), 1.4% (±1.2%) and 1.9% (±1.5%) respectively. There was some evidence that hypoxic exposure favoured those athletes carrying the I allele for angiotensin converting enzyme. In summary, the main finding from the series of studies is that hypoxic tents are likely to enhance sea level endurance running performance by ~1-2%.