Career participation in the National Football League (NFL), compared with limited NFL exposure obtained primarily as a replacement player during a league-wide strike, was not associated with a statistically significant difference in long-term all-cause mortality, according to a study published in JAMA.

Atheendar S. Venkataramani, MD, PhD, from the Department of Medical Ethics and Health Policy, at the Perelman School of Medicine, University of Pennsylvania, and colleagues conducted a retrospective cohort study involving 3,812 retired US NFL players who debuted in the league between 1982 and 1992, including regular NFL players (n = 2,933) and NFL “replacement players” (n = 879) who were temporarily hired to play during a 3-game league-wide player strike in 1987.

The primary outcome was all-cause mortality by December 31, 2016. Cox proportional hazards models were used to compare the observed number of years from age 22 years until death (or censoring), adjusted for birth year, body mass index (BMI), height, and position played. Information on player death and cause of death was obtained from a search of the National Death Index and web-based sources.

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Four career NFL players were excluded from the sample because they died while actively employed on an NFL roster. By the study’s end point, the career NFL players’ mean age was 1.5 years younger than that of NFL replacement players (mean age, 52.7 years vs 54.2 years). Mean BMI and mean height at the time of NFL participation were similar between career NFL players and NFL replacement players (mean BMI, 29.7 vs 29.4; mean height, 187.2 cm vs 187.0 cm).

At the end of the follow-up, 144 NFL players (4.9%) and 37 replacement players (4.2%) were deceased (adjusted absolute risk difference, 1.0%). The adjusted mortality hazard ratio for NFL players relative to replacements was 1.38. Among career NFL players, the most common causes of death were cardiometabolic disease (n = 51; 35.4%), transportation injuries (n = 20; 13.9%), unintentional injuries (n = 15; 10.4%), and neoplasms (n = 15; 10.4%). Among NFL replacement players, the leading causes of death were cardiometabolic diseases (n = 19; 51.4%), self-harm and interpersonal violence (n = 5; 13.5%), and neoplasms (n = 4; 10.8%).

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“Among NFL football players who began their careers between 1982 and 1992, career participation in the NFL, compared with limited NFL exposure obtained primarily as an NFL replacement player during a league-wide strike, was not associated with a statistically significant difference in long-term all-cause mortality,” the authors concluded. “Given the small number of events, analysis of longer periods of follow-up may be informative.”

In an accompanying editorial, written by Steven T. DeKosky, MD, Michael Jaffee, MD, and Russell Bauer, PhD, from the College of Medicine at the University of Florida, stated, “Although the life expectancy of professional football players was not significantly reduced based on the current evidence, the health of professional athletes should remain a focus of future research. Clinicians and researchers should now turn to the pressing issues of understanding how such repeated trauma leads to manifestations of neurodegenerative disease (and sometimes overlapping cognitive, neuropsychiatric, and movement disorders such as parkinsonism, tremor, and depression) and why and how altered tau protein plays a role in [developing] CTE. The field now has the capability to use a variety of biomarkers, such as neurofilament protein or tau imaging, as diagnostic aids, and may well use blood biomarkers and advanced neuroimaging techniques to both confirm the diagnosis and monitor treatments as they are developed.”


  1. Venkataramani AS, Gandhavadi M, Jena AB. Association between playing American football in the National Football League and long-term mortality. JAMA. 2018 Feb 1. doi: 10.1001/jama.2018.0140
  2. DeKosky ST, Jaffee M, Bauer R. Long-term mortality in NFL professional football players: No significant increase, but questions remain. JAMA. 2018 Feb 1. doi: 10.1001/jama.2017.20885