Concussion Legacy Foundation response to the NFHS statement on Tackle Can Wait

The National Federation of High School Athletic Associations recently released a column critical of the Concussion Legacy Foundation’s Tackle Can Wait campaign titled, “No Linkage to CTE From Playing High School Football.” Tackle Can Wait encourages parents to wait to enroll their children in tackle football until high school, and is based on the shocking findings in the new VA and Boston University-led study Duration of American Football play and chronic traumatic encephalopathy published in Annals of Neurology.

In this study of the brains of 266 deceased football players, 223 of whom developed CTE, we learned that while the odds of developing CTE after one season of football are clearly low, the odds of developing CTE go up by 30% per year after that, doubling every 2.6 years.

What is remarkable about this study is the strength of the association. A test of how likely the association between football and increased odds of CTE is to be real, known as a p-value, is 0.0000000038, meaning there is about a four in one billion chance that more years of football doesn’t increase one’s risk of developing CTE. In fact, the correlation between years of football and CTE is stronger than similar studies of smoking and lung cancer, which is why we were comfortable developing a PSA that shows youth football players smoking cigarettes. Our point is that with this new data, we should look at both smoking and tackle football as inappropriate for children.

We believe the NFHS response to Tackle Can Wait illustrates the challenge of effectively communicating that tackle football is not worth the risk before high school but may be worth the risk during high school. In 2018, we explained why high school football is different in our Why Age 14 infographic. This new study provides evidence that we could prevent future CTE cases by shortening careers, and the logical way to shorten careers is to delay when children begin playing.

Tackle football is unique because if nobody played until high school, 94% of American football players would play four or fewer seasons in their lifetime. This is primarily because football is so dangerous that former players don’t throw on helmets and play on the weekends as adults. Since adults better understand the risks, they require being paid to play tackle football through salaries or scholarships, and many, like Chris Borland, Andrew Luck, and Rob Gronkowski, retire young because they don’t believe the risks are worth millions of dollars.

For the 94% who only play in high school, the absolute risk of CTE would be low, and for the remaining 6%, if they choose to continue playing and accumulate increased odds of developing CTE, they would be making that choice as an adult over the age of 18, the culturally recognized age of consent.

As we try to estimate absolute risk of developing CTE from high school football, we have one study that helps guide us. A team led by Dr. Kevin Bieniek examined the brains of 300 former athletes and 450 non-athletes for CTE. They found that among 15 football players who played beyond high school, 46.7% had CTE, and had a significantly higher risk than non-athletes. Among 124 football players who never played beyond high school, 12% had CTE pathology, twice the rate of non-contact sport athletes, but it did not reach statistical significance.

When this finding is combined with the BU study, the state of the science today is that each year of playing tackle football increases your relative odds of developing CTE. It is not yet clear that a high school-only football career would significantly increase your absolute risk of developing CTE pathology. NFHS referenced a JAMA study of 4,000 men who graduated from Wisconsin schools in 1957 and found no difference in cognitive function or decline between those who played football and those who did not as they reached age 65. The men played in an era where youth tackle football was not nationally promoted and not widely played – in our opinion, they represent what we hope would be the outcome from a high school-only football career.

But, to be clear, if a child starts tackle football at age 5 and plays 13 seasons through high school, we are confident all future studies will prove he will have an elevated absolute risk of CTE, and that’s why we discourage youth tackle football.

While we may not agree with every statement in its column, NFHS has a track record of helping change the culture of concussions and stewarding changes to sports to reduce the long-term neurological risk. NFHS has been a terrific partner to the Concussion Legacy Foundation’s Team Up Speak Up concussion education program, which activates coaches to have a conversation with their team about speaking up when they suspect a teammate has a concussion. NFHS has also been a driving force behind contact practice restrictions that we believe should reduce future CTE risk by reducing subconcussive head impacts.

However, we must address one message from the NFHS column that invites further elucidation. Studies of concussions and references to better concussion management are made in the column. All CTE studies from Boston University have found no correlation between diagnosed concussions and elevated CTE risk; it appears that all head impacts, both concussive and subconcussive, contribute to CTE risk. We also have no evidence-based reason to believe better concussion management will reduce CTE risk, although better concussion management will reduce risk of long-term concussion symptoms and is encouraged.

While CLF and NFHS may not agree on every nuance of the science and how it is communicated to parents so they can make the most informed choices for their children, we are all committed to promoting safer sports. CLF proudly stands firm with the message that Tackle Can Wait until high school.