Citation Nr: 18158332 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-47 795 DATE: December 14, 2018 ORDER Service connection for chronic obstructive pulmonary disease (COPD), as secondary to post-traumatic stress disorder (PTSD) is granted. FINDING OF FACT 1. The Veteran is service connected for PTSD. 2. The evidence of record indicates that the Veteran’s COPD is caused by his history of smoking, which is secondary to PTSD. CONCLUSION OF LAW The Veteran’s service-connected PTSD substantially and materially contributed to his COPD. 38 U.S.C. §§ 1110, 1310, 5107 (2012); 38 C.F.R. §§ 3.5, 3.102, 3.303, 3.310, 3.312 (2017); VAOPGCPREC 6-2003 (October 28, 2003). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1969 to September 1970. He received the Combat Infantryman Badge, among other decorations, for this service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey denying service connection for COPD. Secondary service connection for COPD, as secondary to post-traumatic stress disorder (PTSD) is granted. The Veteran is seeking service connection for COPD. He maintains two theories of entitlement. First, he contends that his COPD was caused by Agent Orange exposure in Vietnam. Alternatively, he contends his COPD is caused by smoking, which began as a coping mechanism caused by his service-connected PTSD. See June 2013 Statement in Support of Claim, and statements received in October 2014 and September 2016. The Board finds that the Veteran’s COPD is secondary to his PTSD, which caused his tobacco abuse. Generally, direct service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). General Counsel Opinion 6-2003 recognizes that 38 C.F.R. § 1103 (a) and 38 C.F.R. § 3.300 (a) prohibit service connection for any condition that is attributable to a veteran’s use of tobacco during service. However, it also states that the “plain language of the statute and regulation do not bar a finding of secondary service connection for a disability related to the veteran’s use of tobacco products after the veteran’s service, where the disability is proximately due to a service-connected disability that is not service connected on the basis of being attributable to the veteran’s use of tobacco products during service.” See VAOPGCPREC 2-2003. Service treatment record are silent to COPD, nor are there any complaints, symptoms, or diagnosis of a breathing problem in service. At no point during service was the Veteran diagnosed with COPD. Post-service treatment records at the Miami VAMC reflect the Veteran had a diagnosis of COPD in 2016. These records also reflect the Veteran was a smoker, with a smoking history of more than 45 years. There are no examinations concerning etiology of COPD of record. The Veteran states that he is entitled to service connection for his COPD because he began smoking during service, and continued after service, to help cope with his service-connected PTSD. Considering General Counsel Opinion 6-2003 at issue in this case is: (1) whether a service-connected disability (PTSD) caused the Veteran to use tobacco products after service; (2) if so, whether the use of tobacco products, as a result of PTSD, was a substantial factor in causing secondary disability (COPD); and (3) whether the Veteran’s COPD would not have occurred but for the use of tobacco products caused by the Veteran’s PTSD. See VAOPGCPREC 6-2003. In a December 2014 statement, the Veteran asserts that after leaving service and returning stateside he felt feelings of emptiness and latent anger which caused him to self-medicate with alcohol and tobacco. The Veteran considered himself a habitual user of cigarettes for the better part of 30 years. Moreover, in the Veteran’s September 2016 Form 9, he again expounded that the onset of his tobacco use was in service, and continued for 40 years after to cope with anxiety related to later diagnosed combat-related PTSD. The September 2013 VA examination for PTSD noted the Veteran’s smoking habit as relevant substance abuse history, and stated the Veteran had reduced smoking to one pack every 2-3 days, at the time of the examination. In the October 2014 Memorandum in Support of Notice of Disagreement, the Veteran argued cigarette smoke to be the most common risk factor for the development of COPD. According to said memo, this assertion is supported by the Institute of Medicine (IOM) which also found the most important risk factor for many noncancerous respiratory disorders to be cigarette smoke. In an August 2015 statement, the Veteran’s treating physician for COPD, Dr. K.G., opined that the Veteran’s COPD is at least as likely as not causally related to cigarette smoke inhalation. As a rationale for that opinion, Dr. G. pointed out that cigarette smoking is the leading cause of COPD. Additionally, he concluded that the Veteran’s use of nicotine is at least as likely as not causally related to his long-standing combat related PTSD. In support of this notion, he noted that a significant body of medical and scientific research documents a correlation between PTSD and tobacco use; specifically, the seminal study on cigarette smoke inhalation and PTSD among Vietnam veterans. A February 2018 opinion from C.N., the Veteran’s psychologist concluded that PTSD increased stress which can increase smoking and it is more likely than not connected to the Veteran’s service. The Board finds the most competent, credible, and probative evidence of record establishes that the Veteran’s post-service continued use of tobacco products, due to his PTSD, was a substantial factor in the development of COPD. (Continued on the next page)   The Veteran competently and credibly reports that his service-connected PTSD caused his tobacco abuse during and after service. This is supported by Dr. G. and C.N. who both explained that PTSD can cause increased stress which results in increased smoking. Moreover, of greatest probative value is Dr. G.’s opinion which supports the Veteran’s assertions that his PTSD caused him to self-medicate with smoking, and the smoking in turn caused the COPD. His position was fully grounded in medical literature and based upon a comprehensive review of the Veteran’s claims file, and medical history. Considering the opinion of record is not shown to be directly contradicted by other medical evidence, the Board finds service connection is warranted for COPD. See VAOPGCPREC 6-2003. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Russell, Associate Counsel