America’s most-watched, most-lucrative, most-fan-crazed game instituted several changes this year. The National Football League altered kickoffs to reduce the type of full-speed, bone-crushing tackles that can cause some of the most serious head injuries to players. And it’s allowing players to wear special Guardian Caps for added protection against head injuries.

The NFL lauded its own rule changes as substantial steps to reduce concussions and better protect the brain health of its players. But not everyone celebrated.

Some scientists and researchers who study the impact of blows to the head on the human brain—especially those at Boston University’s world-leading Chronic Traumatic Encephalopathy (CTE) Center—say they were less impressed with the NFL’s actions, for two reasons. First, years of research at BU has revealed that CTE, a degenerative brain disease diagnosed in hundreds of former contact sports athletes, is not caused by isolated incidents of concussions, but rather by smaller repetitive blows to the head that accumulate over months and years. Second, BU research has also shown that players who start playing tackle football at a young age, sustaining more of those smaller head blows in their teenage years, are more likely to suffer from CTE and the long-term, lingering effects that accompany the disease.

While the NFL’s rule changes aim to help its multimillion dollar professional players, teams at the college, high school, and youth football levels continue to use the older, riskier kickoff format, and less protective helmets. And it’s those younger athletes—who the NFL sees as its next generation of fans and players—who need to be protected against CTE developing later in life. 

The numbers are stark: BU researchers have found that the risk of developing CTE is directly correlated with the number of years of football played—not the number of concussions suffered. One BU study found that the risk of developing CTE doubles for every 2.6 years of playing football, which is one reason why the Concussion Legacy Foundation, affiliated with the CTE Center, advises parents to not let children play tackle football until they are 14 years old. 

“Here you have this multibillion [dollar] business where people make so much money, but at least they knew the risk they were taking,” says Michael L. Alosco, a codirector of clinical research at the CTE Center and a Chobanian & Avedisian School of Medicine associate professor of neurology. “Where we are lacking is this trickling down to the college, high school, and youth leagues. They don’t have access to the Guardian Caps NFL players are using and the resources of the NFL. That’s where most people play football, at the high school level, and that’s where the major public health concern is.” 

A Changing Game

Thirty years ago, through the winter of 1994-95, the NFL began its slow transformation into the very different game that is played today. Reacting to serious concussions suffered by several of the league’s star players, including Dallas Cowboys quarterback Troy Aikman, then-league commissioner Paul Tagliabue took a big, if seemingly begrudging, step. Despite describing concussions as merely “an occupational risk,” he created a brain injury committee. 

Since then, dozens of new rules, new equipment, and stiffer penalties have been put in place, all with the intention of trying to reduce the number of concussions players sustain:

In recent years, much of the public pressure for change has built because of research out of the CTE Center, under the direction of Ann McKee, a William Fairfield Warren Distinguished Professor. McKee has previously said she was a “lifelong football fan,” but she now views the game as dangerous and says that “football damages brains, and young brains especially.” 

Her research led to a series of high-profile CTE diagnoses: Hall of Famers John Mackey, Ollie Matson, and Ken Stabler, and New England Patriots tight end, and convicted murderer, Aaron Hernandez. Each, along with a steady drumbeat of other findings, made headlines and helped raise awareness of the disease and the dangers to the brain from contact sports.

In 2016, the league—after reportedly resisting efforts to work alongside BU researchers—acknowledged the link between CTE and football for the first time, with its senior vice president of health and safety policy telling congressional leaders, “I think certainly, based on Dr. McKee’s research, there’s a link, because she’s found CTE in a number of retired football players. I think the broader point…is what that necessarily means and where do we go from here with that information.” That came just after the NFL and the NFL Players Association reached a concussion settlement, promising to make payments to former players and their families if the player was found to have dementia or other brain diseases that could be linked to concussions. So far, the league says it’s paid over $1.2 billion to over 1,600 former players and families. 

Even with that progress, McKee, Alosco, and others would argue that in the eight years since the settlement agreement, the league hasn’t gone very far on the playing field with the lessons their research has uncovered. The NFL touts how concussions in pro football are declining year after year as proof of its efforts—important progress, to be sure. But researchers say that’s merely inflating the misperception of CTE by shifting the conversation toward high-impact concussions and away from the real culprit: moderate, repetitive blows to the head. 

As proof of how even the players are misled by the conversation, days after Miami Dolphins quarterback Tua Tagovailoa suffered a concussion early this season—adding to others he sustained in previous years—some players called for him to retire, saying he had suffered too many concussions.

The Parental Paradox

“The NFL and the players are taking this issue far more seriously than they ever have before,” Chris Nowinski, the cofounder and president of the Concussion Legacy Foundation, tells The Brink. 

His words came only days before a new study was released that found one-third of former pro football players surveyed believe they have CTE. Of the 1,980 respondents in the survey, more than 230 expressed having suicidal thoughts and 176 said they had been diagnosed with some form of dementia.

“It’s a more ethical game at the NFL level,” Nowinski says. “The problem is that if the types of changes the NFL makes don’t impact all of football, it’s not going to matter. We have children in the same costumes, doing the same things the professionals did.”

Nowinski says while some responsibility lies with parents for protecting their children, he puts more onus on the NFL. “When the NFL is creating advertisements with the Manning brothers to recruit young players to the game, the NFL is responsible for much of the confusion in the public.”

Alosco agrees that the NFL needs to do more to support families and younger players.

“The NFL making these changes sets a good example, like limiting tackling in practice. Now they are in a position to provide resources to access these same tools and help implement these same changes at the lower levels,” says Alosco. “But there will be a point when you’ve made all the changes you can make. At the end of the day, football is a violent sport. Without tackling, there is no [NFL] football.”

There are signs, however, that parents are paying attention to the science. As public awareness of CTE research has grown, there has been a decline in participation in youth and high school tackle football and a rise in participation in flag football. One report said the 2021-2022 school year was the first since 2000 when fewer than one million players participated in high school football. And with support from the NFL, NFL FLAG has 1,800 locally operated leagues and 700,000 players nationwide. 

John McCarthy has a unique Boston University perspective on football and CTE—as a coach, a parent, and an educator. He was an assistant football coach at BU in the 1990s, before the school disbanded its program in 1997, and he’s coached high school football. He also is a clinical associate professor of applied human development at BU’s Wheelock College of Education & Human Development, and he leads the Institute for Athletic Coach Education, providing training and education for youth coaches in the community.

“There are some parents who might be increasingly hesitant to let their children play,” McCarthy says. “But the cultural importance of big-time football and scholarships is a pretty big allure. There is a lot of status where people are willing to turn a blind eye [to the risks] and say, that won’t be my kid.”

McCarthy says he thinks there are “genuine good-faith efforts to make the game safer.” But ultimately he wonders if it will take more stories like that of Ray Lewis III to cause more parents to think twice. A former defensive back with the University of Miami and the son of Baltimore Ravens legendary linebacker Ray Lewis, Ray Lewis III died of an accidental drug overdose in 2023. His brain was donated to the CTE Center for research and was found to have stage two CTE. 

“Little did I know when I put my son in tackle football at age five, I ran the risk of having to bury him 22 years later,” Lewis’ mother, Tatyana McCall, said after the diagnosis was made public. “I would have done something different now knowing the risks. We need to wait until our babies are at least 14 to allow them to play tackle football.”

Michael Harper, a BU professor of law emeritus whose expertise lies in labor and employment law, says the NFL has come under increasing cultural pressure as the growing scientific evidence on CTE has emerged. He says one example of tension in the league came when the NFL added games to its schedule; younger players saw the opportunity to earn more money, while more veteran players, who understood the risks better, opposed the change.

Even 30 years after the league commissioner first tried to address head injuries, Harper says the same questions persist. “I still don’t think the leadership of the [NFL Players Association] has given this proper priority,” he says. “That occupational hazard is part of the current culture.”

Nowinski says that until CTE can be diagnosed in the living, not just posthumously, many will struggle to believe the inherent risks of the game. “Everybody you played football with when you were younger, you think they’re fine,” he says. “They may not have symptoms yet. But I wonder what will happen when a 20-year-old is told they have CTE, after playing football since age 8.”