America's Big Football Problem

The damage football is doing and what we need to do about it.

Posted Mar 05, 2018

Football is America’s favorite sport to watch. The tackle version of the game is played by children as young as five. College football has become a big business while the National Football League is estimated to have made $14 billion in 2017. One of us (Jack) has been an avid fan of the New York Giants football team since childhood, watching each televised game passionately.

Recently, however, concerns have mounted that playing tackle football may be associated with serious neurological and psychological consequences. Last year, in a widely reported study published in the Journal of the American Medical Association (JAMA), researchers from Boston University examined the post-mortem brains of 111 former NFL players and found that 110 of them met pathological criteria for chronic traumatic encephalopathy (CTE). CTE is a progressive neurodegenerative disease caused by repetitive head trauma that can only be diagnosed on examination after death. Many of the players whose brains were examined had serious behavioral and cognitive disturbances during life, however.

These were, of course, donated brains rather than a randomly obtained sample, making it impossible to assign a true prevalence rate of CTE among professional football players. But the high rate observed in the JAMA study, coupled with sensational cases of suicides and homicide perpetrated by former players who turned out to have CTE, alerted the scientific community and the public that playing tackle football might be dangerous.

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Source: Shutterstock

A more recent study in JAMA hinted at the possibility of early mortality in long-term NFL career players compared to a group of replacement players who participated only during a one-year strike period. Because the overall mortality rates were low in that study, the numerical difference between groups was not statistically significant. Nevertheless, the study is another piece of evidence that playing football is a health risk.

If the problem were only in adults who choose to play football to earn a living, one might conclude that with proper disclosure of the risks the decision to play in the NFL is a personal one. But another study that was treated as a bombshell by the popular media suggests that even children who play football, including those who do not go on to play professionally, may be at risk. This time, researchers, again from Boston University, divided a group of 214 men of mean age 51 years into those who started playing football before age 12 and those who started playing after age 12. The group of earlier first exposure to football “had >2× increased odds for clinically meaningful impairments in reported behavioral regulation, apathy, and executive function, and >3× increased odds for clinically elevated depression scores.”

The authors of that study acknowledge many limitations, including the fact that the sample was composed of people who voluntarily responded to a survey request, introducing the possibility of ascertainment bias. But these authors also point out that other studies have found that youth participation in tackle football is associated with abnormalities on neuroimaging and behavioral and cognitive measures.

The NFL itself has shown interest in researching the effects of repeated head trauma and CTE, but some have called into question its sincerity. Kathleen Bachynski and Daniel Goldberg argue in a recent article in BMJ Injury Prevention  that the research relationship between the NFL and the CDC represents a conflict of interest. Is the NFL acting like other industry giants such as tobacco, pharmaceuticals, sugar producers, and automobile manufacturers in trying to obfuscate the dangers of its product by purchasing the imprimatur of a trusted regulatory agency?

Jack recently overheard a radio sports announcer and former NFL player say that he did not feel there was yet “enough evidence” to warrant restricting children from playing tackle football. But sometimes, and perhaps, in this case, the refrain “not enough evidence” is used by climate deniers and others who dislike what the scientific evidence is showing. Americans love football just like we love driving our cars with fossil fuels, so it will take a lot to convince us that football may be a risky endeavor.

In most states, we do not allow people under the age of 18 to smoke cigarettes. You have to be 21 to purchase alcohol. Many states require highly regulated car seats for children. Parents are not given discretion in these matters; we have decided as a society that cigarette smoking, alcohol consumption, and driving in an automobile carry risks that children and adolescents are not mature enough to adjudicate. Therefore, we pass laws to protect them from these dangers that even their parents cannot circumvent.

To be sure, the data on the risks of playing tackle football is nowhere near as complete as are those about cigarette smoking, alcohol consumption, or driving in a car. We know with certainty that those three pose dangers and that those dangers are even greater for youth than for adults. But how much evidence is enough to want to protect children from what could be irreversible neuropsychiatric harm? We know parents for whom a single newspaper article about a consumer product having toxic potential is sufficient to ban it from their homes in order to prevent their children from coming into contact with it. While the data on football is not yet conclusive, they certainly suggest that playing football at a young age, even without continuing to participate into college years, may cause permanent behavioral and cognitive disturbances. If we do not let our children smoke or drink, then should we let them play tackle football before attaining an age at which they can make their own decisions?

The hardest scientific evidence to accept is always that which seems to suggest we should not do something we like doing. If a study is published saying that alcohol consumption prolongs lifespan, we easily accept those results. Learning that cigarette smoking, getting a suntan, and eating highly processed foods are dangerous was not greeted initially with great enthusiasm. We must ask ourselves how much evidence is enough to stop children from playing tackle football, lest we run the risk of punting on an important decision and exposing them to danger.

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