Importance Studies of the longevity of professional American football players have demonstrated lower mortality relative to the general population but they may have been susceptible to selection bias. Objective To examine the association between career participation in professional American football and mortality risk in retirement. Design, Setting, and Participants Retrospective cohort study involving 3812 retired US National Football League (NFL) players who debuted in the NFL between 1982 and 1992, including regular NFL players (n = 2933) and NFL “replacement players” (n = 879) who were temporarily hired to play during a 3-game league-wide player strike in 1987. Follow-up ended on December 31, 2016. Exposures NFL participation as a career player or as a replacement player. Main Outcomes and Measures The primary outcome was all-cause mortality by December 31, 2016. Cox proportional hazards models were estimated to compare the observed number of years from age 22 years until death (or censoring), adjusted for birth year, body mass index, height, and position played. Information on player death and cause of death was ascertained from a search of the National Death Index and web-based sources. Results Of the 3812 men included in this study (mean [SD] age at first NFL activity, 23.4 [1.5] years), there were 2933 career NFL players (median NFL tenure, 5 seasons [interquartile range {IQR}, 2-8]; median follow-up, 30 years [IQR, 27-33]) and 879 replacement players (median NFL tenure, 1 season [IQR, 1-1]; median follow-up, 31 years [IQR, 30-33]). At the end of follow-up, 144 NFL players (4.9%) and 37 replacement players (4.2%) were deceased (adjusted absolute risk difference, 1.0% [95% CI, −0.7% to 2.7%]; P = .25). The adjusted mortality hazard ratio for NFL players relative to replacements was 1.38 (95% CI, 0.95 to 1.99; P = .09). 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%). Conclusions and Relevance 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. Given the small number of events, analysis of longer periods of follow-up may be informative.

中文翻译：

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在美国国家橄榄球联盟打美式足球与长期死亡率的关系

重要性 对职业美式足球运动员寿命的研究表明，相对于一般人群而言死亡率较低，但他们可能容易受到选择偏差的影响。目的研究职业美式橄榄球职业参与与退休后死亡风险之间的关联。设计、设置和参与者 回顾性队列研究涉及 3812 名在 1982 年至 1992 年间首次亮相 NFL 的美国国家橄榄球联盟 (NFL) 退役球员，包括常规 NFL 球员 (n = 2933) 和 NFL“替补球员”(n = 879)他们在 1987 年的 3 场全联盟球员罢工期间被临时聘用。后续行动于 2016 年 12 月 31 日结束。暴露了 NFL 作为职业球员或替补球员的参与。主要结果和措施 主要结果是截至 2016 年 12 月 31 日的全因死亡率。估计 Cox 比例风险模型以比较从 22 岁到死亡（或审查）的观察年数，并根据出生年份、体重指数进行调整、高度和播放位置。通过对国家死亡指数和网络资源的搜索，确定了有关玩家死亡和死因的信息。结果 在本研究中包括的 3812 名男性（首次参加 NFL 活动时的平均 [SD] 年龄，23.4 [1.5] 岁）中，有 2933 名职业 NFL 球员（NFL 任期中位数，5 个赛季 [四分位距 {IQR}，2-8 ]；中位随访，30 年 [IQR，27-33]）和 879 名替补球员（中位 NFL 任期，1 个赛季 [IQR，1-1]；中位随访，31 年 [IQR，30-33] ）。在随访结束时，144 名 NFL 球员 (4.9%) 和 37 名替补球员 (4. 2%) 已死亡（调整后的绝对风险差异，1.0% [95% CI，-0.7% 至 2.7%]；P = .25）。NFL 球员相对于替补球员的调整后死亡率风险比为 1.38（95% CI，0.95 至 1.99；P = .09）。在职业 NFL 球员中，最常见的死亡原因是心脏代谢疾病（n = 51；35.4%）、交通伤害（n = 20；13.9%）、意外伤害（n = 15；10.4%）和肿瘤（n = 15；10.4%）。在 NFL 替补球员中，死亡的主要原因是心脏代谢疾病（n = 19；51.4%）、自残和人际暴力（n = 5；13.5%）和肿瘤（n = 4；10.8%）。结论和相关性 在 1982 年至 1992 年间开始职业生涯的 NFL 足球运动员中，职业生涯参与 NFL、与在全联盟罢工期间主要作为 NFL 替补球员获得的有限 NFL 暴露相比，与长期全因死亡率的统计学显着差异无关。鉴于事件数量较少，对较长时间随访的分析可能会提供信息。