Super Bowl weekend. The big game, the big TV ads, the big halftime show, the big bowls of chips and salsa … and the big hits. Dramatic hits that make some of us cheer, make others cringe, and make some players retire.

A recent paper in the BMJ’s Injury Prevention journal raises questions about the National Football League’s approach to sports-related, traumatic brain injuries (sTBI). In particular, the authors argue that the NFL partnering with the CDC to get the word out about those injuries represents a conflict of interest.

“We should be very skeptical about the NFL providing a grant to the CDC to address the very health problem associated with their sport,” said co-author, Kathleen Bachynski, PhD, a postdoctoral fellow in medical humanities and ethics at NYU School of Medicine.

“The CDC’s mission is to provide the highest quality scientific evidence to help the American public make informed health decisions. That’s not the goal of the NFL. Their bottom line is increasing sales, viewership, and promoting their league and products.”

Bachynski says the NFL has a well-documented history of “downplaying and misleading” when it comes to the evidence regarding TBI and repeated full-body collisions. She believes the NFL may simply be trying to buy credibility from the esteemed CDC in an attempt to — not just shape the public narrative on sTBI — but also divert attention away from their substantial role in contributing to the problem.

“This helps the NFL frame brain trauma so people see it as a health issue across all sports and activities, without mentioning the increased risk in full body collision sports like football,” she said. “It’s the same tactic that big pharma and the tobacco industry have used.”

[Update 1/31/18: The CDC’s credibility has further been called into question today with news that Director Brenda Fitzgerald bought shares in a global tobacco company while leading an agency charged with reducing tobacco use.]

TBI: How the NFL frames it

If you go to the NFL-sponsored content on the CDC’s website you’ll find an emphasis on preventing concussions through education, and minimizing their impact through post-injury management.

[Update (2/27/18): We were alerted today via Twitter by Dr. Bachynski (@bachyns) that “the CDC website appears to have taken down its NFL partnership page.” Therefore, the above “NFL-sponsored content” link is now broken.]

You’ll also find this framing of the issue by Roger Goodell, the league’s commissioner, in this video link from the CDC website:

“We know we set a standard … when we change our approach, other’s take notice and they will follow … NFL players receive the most up-to-date medical information on all issues — including concussions — and I believe they receive the best medical treatment in all of sports, and probably the world.”

Daniel Goldberg, an associate professor at the Center for Bioethics and Humanities at the University of Colorado – Anschutz Medical Campus, and a co-author with Dr. Bachynski on the BMJ study, calls the CDC partnership part of the NFL’s playbook for “manufacturing doubt.”

“They try to purchase credibility from a well-respected public health institution, because they’ve lost theirs,” he said. “But just like tobacco, pharma, and the lead, vinyl, and asbestos industries — they use questionable or incomplete evidence for their own commercial interests.”

“What’s subtle and tricky about the NFL’s concussion fact sheets is that they’re not wrong. Just incomplete,” added Bachynski.

“The emphasis is on the management side and it fails to highlight the consequences of repetitive, hidden, subconcussive trauma that can come from every day contact. It also deflects responsibility on to players and their families, and suggests taking these steps will mitigate the risks when they won’t. It’s never been proven that brain damage to players can be prevented through education or post-injury management alone.”

What we know and don’t know

But there’s more to the story says Sean Engel, MD, a sports medicine physician at the University of Minnesota, who senses that popular culture and belief are tending to outpace the evidence in this area.

“Repetitive, subconcussive trauma is certainly a concern, but there’s still no consensus on whether it leads to brain damage,” said Engel.

“And there’s probably good reason for this lack of evidence. Mainly, the definition of what is subconcussive? Because that would include everything up to a concussion. So anything that jostles your brain and doesn’t cause a concussion would then be considered a ‘subconcussive blow.’ So if you put it in that context, you can begin to understand just how hard it is to define, study, and evaluate subconcussive blows. Let alone prove causality.”

The scientific literature on this topic is polarized. There are many examples of studies which support the notion of cumulative trauma being detrimental. There is also evidence that players who don’t have a history concussions may not face increased neurocognitive risk.

This, in turn, can lead to opposing camps of public opinion: One is cautious, advocating against collision sports, and eagerly promoting evidence (even mouse studies) that supports their view; the other is saying ‘not so fast,’ we might be unnecessarily alarming athletes and their families that brain damage is inevitable.

“Remember that this research is relatively new by medical and scientific standards,” said Engel. “We need more data. Until then, you can sort of understand why the approach to athletes in collisions has become ‘when in doubt, get them out.’ That approach wasn’t around 10 or 15 years ago.”

Can we trust the NFL-CDC partnership?

Is the NFL trying — as Dr. Goldberg alleges above — to ‘manufacture doubt’ on this issue? It’s certainly a strategy we’ve encountered before.

A good example that has generated some excellent journalism is Coca-Cola and it’s many attempts to deflect blame from its trademark sugary drink.

“Behind the scenes of the Times’ takedown of a Coke-funded ‘front group”

Coca-Cola’s secret influence on medical and science journalists

Although it seems obvious, remember what’s at play here: When your product is proven to be harmful, how do you divert attention from those harms?

It’s a question worth pondering as over 100 million of us watch the Super Bowl this weekend. The NFL makes billions (over $13 billion in 2015) in revenue. It’s not hard to enjoy the athleticism of these talented athletes. What may be harder is admitting the oxymoron that it’s a ‘violent game.’ That the NFL’s response to this has been inadequate and inconsistent. When it comes to public opinion regarding head injuries, the NFL has a lot at stake.

“Given their track record of downplaying or denying the risks of brain trauma from football –despite evidence to the contrary — we don’t find the NFL very trustworthy on this issue,” says Bachynski.

“And we think it’s important that the CDC has trustworthy partners. Because they need to maintain the public’s trust that they provide independent and accurate information.”