Citation Nr: 21005147 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 17-40 018A DATE: January 29, 2021 ORDER Entitlement to service connection for the cause of the Veteran’s death is denied. FINDINGS OF FACT 1. The Veteran’s death certificate listed his immediate cause of death as cardiovascular collapse; due to (or as a consequence of) bilateral pneumonia; due to (or as a consequence of) severe chronic obstructive pulmonary disease (COPD), the underlying cause of death. 2. At the time of his death, the Veteran was not service connected for any disease or injury. 3. The preponderance of the evidence is against a finding that the immediate or contributory causes of the Veteran’s death manifested during active service or within one year of separation, or were otherwise related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for the cause of the Veteran’s death have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1310, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served honorably in the United States Navy from September 1953 to March 1957, and in the Army from May 1970 to June 1970. Unfortunately, he died in April 1996. The appellant is the Veteran’s surviving spouse. In June 2020, the Board of Veterans’ Appeals (Board) reopened the claim and remanded it for further evidentiary development. The matter now returns to the Board for review. Service connection for the cause of the Veteran’s death The appellant seeks service connection for the cause of the Veteran’s death based on a number of theories, discussed in detail below. Dependency and Indemnity Compensation (DIC) benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. § 3.5(a)(1). A veteran’s death will be considered as being due to a service-connected disability when the evidence establishes that the service-connected disability was either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a). Service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one that is not related to the principal cause. In order for a service-connected disability to be determined as a contributory cause of a veteran’s death for compensation purposes, it must be shown that it contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. It is not sufficient to show that it causally shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994). In determining whether service connection for cause of death is warranted, the laws and regulations generally applicable to compensation for service-connected disability apply. 38 U.S.C. § 1310. In this regard, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). For a DIC claim based on cause of death, the first Romanowsky requirement, “evidence of a current disability, will always have been met (the current disability being the condition that caused the veteran to die).” Carbino v. Gober, 10 Vet. App. 507, 509 (1997), aff’d sub nom. Carbino v. West, 168 F.3d 32 (Fed. Cir. 1999). In addition, for veterans who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain chronic diseases, provided the disease is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)). As with all claims for disability compensation, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A review of the pertinent evidence of record reveals the following. The Veteran’s service treatment records show that in January 1954, he was hospitalized due to generalized myalgia and swelling of the ankles and right knee; he denied recent upper respiratory infection but reported a sore throat. On physical examination he had a reddened pharynx as well as tenderness and redness involving the cervical vertebrae, right ulna, and right knee. His heart sounded well and of fine quality, and an initial EKG was within normal limits. The Veteran was treated with antibiotics. The diagnosis was rheumatic fever without heart involvement. In February 1954, the Veteran was treated for sore throat and coughing; he was diagnosed with acute bronchitis and administered antibiotics. He became afebrile and asymptomatic in 24 hours; a final X-ray was negative. There are other references in the Veteran’s service treatment records to occasional colds. Thereafter, while serving aboard the USS Kawishiwi, records indicate the Veteran reported suffering a head wound in July 1956 after flipping off a ladder. Subsequent complaints of headache were noted in July, August, and September 1956. Swollen lymph glands were noted in August 1956. In January and February 1957, he was treated for pyelitis (organism unknown) and a pilonidal cyst, which rapidly improved with treatment. In March 1957, the Veteran underwent an examination in connection with his release from his first period of active duty; at that time, his heart, vascular system, and lungs were noted to be normal. In July 1957, the Veteran was treated for an additional pilonidal cyst. Records from July 1959 reference right leg cellulitis, which was noted to have almost cleared with several days of treatment; these records also reference headaches, a cold sore in the mouth, and lymphadenitis. In September 1959, the Veteran reported chest pains; however, a physical examination was negative. The record reflects that in the late 1960s, prior to entering his final period of active service, the Veteran sustained injuries to his spine and left knee when he was struck by a camper. He testified (at a January 1974 RO hearing and later at an April 1974 Board hearing) that he was hospitalized for more than a year and underwent multiple surgical procedures on his left knee and ultimately his lower back as a result of this accident. In January 1970, the Veteran was examined prior to entering active duty; the report notes a preexisting left knee injury, specifically osteoarthritis secondary to old trauma. He was discharged for failure to meet medical fitness standards. According to a June 1970 separation examination report, his heart, vascular system, and lungs were normal. On an accompanying Report of Medical History, the Veteran denied having asthma, shortness of breath, chest pain, chronic or frequent colds, heart symptoms, or blood pressure abnormalities. In September 1971, the Veteran was treated a VA facility for chest pains that were worse with deep breathing and left arm movement. X-rays were within normal limits except for a probable old rib fracture. It was also noted that an EKG was within normal limits. The diagnosis was chest pain of musculoskeletal etiology. On December 1971, the Veteran underwent surgery on his left knee. A chest X-ray and EKG were normal. At an Apri 1974 Board hearing, the Veteran explained that he developed rheumatic fever in service in conjunction with a left knee injury; he did not report ongoing heart or lung pathology. He denied experiencing mental health problems in service but argued that he developed a “nervous condition” as a result of his knee problems. In October 1974, the Veteran underwent a VA examination; the report noted that his cardiovascular system and lungs, including chest X-ray, were normal. A psychiatric evaluation noted a diagnosis of passive-aggressive personality disorder. In late October 1974 and continuing into November, the Veteran was hospitalized with a diagnosis of anxiety neurosis with depression and other orthopedic diagnoses. In a February 1975 decision, the Board denied the Veteran’s claims of entitlement to service connection for a bilateral knee disability and a psychiatric disorder. That decision became final. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 20.1100(a), 20.1104. The Veteran filed a claim in January 1977 seeking service connection for emphysema; he reported that he was currently hospitalized for the disease and claimed (without further explanation or medical documentation) that he had developed emphysema while in basic training. In a February 1977 rating decision, the Atlanta, Georgia RO denied the claim. In April 1977, the Veteran was admitted to a VA medical facility with symptoms of anxiety and drug abuse. In December 1978, a VA dental treatment note reflected a history of bullous emphysema with onset in January 1977; the Veteran stated that he felt good except for occasional shortness of breath. Medical records dated in January 1979 show that the Veteran was seen with complaints of chest pains radiating into his left arm. He was hospitalized with an admission diagnosis of bullous emphysema of the left upper lobe. He underwent a partial left upper lobectomy and flexible fiberoptic bronchoscopy and was noted to be improved at discharge. The Veteran was privately hospitalized in April and May 1979 for lower back problems. Treatment records from this hospitalization also mention that he had been hospitalized almost yearly from 1966 to 1975, mostly for lower back problems but sometimes for lower respiratory tract infections. On physical examination in April 1979, it was noted that the Veteran’s heart was not clinically enlarged, and no murmurs or friction rubs were appreciated. The Veteran was reported to be a “rather heavy” cigarette smoker. Clinical impressions included COPD and status post thoracotomy for removal of emphysematous blebs. (The examiner noted the possibility of tuberculous infection, but there is no evidence such a diagnosis was ever clinically indicated.) A July 1979 Social Security Administration (SSA) decision notes various ailments, with lung problems treated in late 1978 and thereafter. Other medical records from 1979, including VA hospitalization records from September and October 1979, note diagnoses of COPD and status post thoracotomy for emphysematous blebs. These records indicate that the Veteran was a heavy cigarette smoker. In January 1981, the Veteran underwent an aortofemoral bypass at a private hospital. Diagnoses included Leriche syndrome (aortoiliac occlusive disease), COPD, coronary artery disease, benign prostatic hypertrophy, and status post resection of bladder tumor. In August 1982, the Veteran was hospitalized with complaints of shortness of breath with chest pain and anxiety. It was noted that he smoked a pack of cigarettes every day and had done so for the previous 30 years. The Veteran underwent a right and left heart catheterization, a coronary arteriogram, and a bronchoscopy; the catheterization revealed significant single vessel coronary disease with probably inducible myocardial ischemia. His diagnoses included bronchitis, bullous emphysema, COPD, tobacco abuse, coronary artery disease, and mild angina. In August 1983, the Veteran was privately hospitalized due to persistent chest pain and dyspnea with effort. The impression was bullous emphysema with air trapping in the right upper lobe; residual coronary artery disease needed to be ruled out. Treatment records also showed COPD. The Veteran underwent a partial resection of the right upper lobe to remove bullae that were intermittently inflamed and causing chest wall pain. A pathology report found peripheral emphysema with large bullae, fibrosis, focal areas of calcification and chronic inflammation in lung tissue. Medical records from 1990 to 1994 show that the Veteran continued to require treatment for cardiovascular and pulmonary difficulties. In December 1990, the Veteran complained of daily chest pain and dyspnea on exertion; he underwent cardiac catheterization and an arteriogram. The diagnosis was acute COPD exacerbation with normal coronary arteries and no evidence of coronary artery disease; however, peripheral vascular disease of a significant degree was noted. Other records from December 1990 show Leriche’s syndrome, severe COPD, and severe bullous emphysema, as well as “horrible” pulmonary functioning. A chest X-ray again found COPD, but without evidence of acute cardiopulmonary process. The Veteran underwent extensive pulmonary physical therapy and an aortobifemoral bypass in January 1991. In March 1991 he was seen with complaints of increasing dyspnea, a non-productive cough, and wheezing for approximately one week following an upper respiratory infection. He was described as a “chronic heavy smoker.” The impressions were exacerbation of COPD secondary to acute bronchitis, and bullous emphysema. In March 1994, the Veteran presented with a deteriorating respiratory condition. He continued to report a “heavy smoking habit.” He was hospitalized; the impression was bullous emphysema and persistent bronchospasm with poor exercise tolerance. The Veteran’s occupational history included “many years of employment in shipyards and also working as a sandblaster.” X-rays taken in May 1994 noted that the Veteran’s results were “consistent with asbestosis.” In August 1994, the Veteran was again hospitalized for respiratory symptoms. Diagnoses included exacerbation of COPD, a left upper lobe chest mass, and bronchitis. In consultation records, he was described as “a very heavy cigarette smoker for many decades.” He was also described as a “chronic smoker with advanced emphysema.” In September 1994, the Veteran was re-hospitalized at a private hospital with a COPD/emphysema exacerbation. He had rapidly progressing COPD and a left upper lobe nodule. He also had possible chronic myelogenous leukemia. He had continuing difficulty with COPD/emphysema symptoms in October 1994, with a decrease in the size of the left upper lobe nodule. He had a history a cigarette abuse. It was noted that he was “retired from metal fitting, with a history of asbestos exposure,” along with a history of cigarette abuse. Further evaluation (including bone marrow review) also indicate that he did not have a chronic myelocytic leukemia but rather an intermittent leukemoid-type reaction most commonly stimulated by infection or stress. The Veteran was hospitalized in April 1996, with complaints of shortness of breath, severe right chest wall pain, nausea, vomiting, and diarrhea. It was indicated that he smoked five cigarettes per day and had reportedly smoked a pack a day for 40 years. He had recently had pneumonia. Impressions were acute viral gastroenteritis with dehydration, COPD with possible underlying acute exacerbation, pleurisy, chronic myelogenous leukemia, history of coronary artery disease, and severe large vessel and peripheral vascular disease. There were references to multiple past operations for cardiovascular and lung disorders, including angioplasties, aortofemoral bypass grafting, carotid endarterectomy, and for emphysematous blebs. The Veteran died later that month. According to the Veteran’s death certificate, the immediate cause of death was cardiovascular collapse; due to (or as a consequence of) bilateral pneumonia; due to (or as a consequence of) severe COPD, the underlying cause of death. Nicotinism was a significant condition contributing to death, but not resulting in the underlying cause. During the Veteran’s lifetime, service connection was not established for any disease or injury. He was in receipt of a permanent and total disability rating for purposes or a non-service-connected VA pension, based on a lower back disability and COPD with resection of the left lung. The appellant contends that the cause of the Veteran’s death should be service connected based on various theories, including tobacco use, asbestos exposure, emphysema, and heart problems due to rheumatic fever; she specifically argues that disease associated with rheumatic fever caused the Veteran’s health to deteriorate steadily as well as chronic myelogenous leukemia. In essence, she asserts that the Veteran suffered disability in service that affected his vital organs and thus led to his eventual demise. The appellant also asserts that there was a causal relationship between the Veteran’s psychiatric disorders, including anxiety and posttraumatic stress disorder (PTSD), and the conditions that caused the Veteran’s death. In addition, the appellant has referred to various in-service complaints, including such varied conditions as headaches, boils, pilonidal cysts, head wound injury, scalp infestation, malaise, bronchitis, myalgia, and bilateral knee injuries, among others. In support of her contentions, the appellant has submitted excerpts of medical articles that discuss rheumatic fever. One excerpt noted that a substantial percentage of people with a first attack of rheumatic fever have heart inflammation with valve involvement. In November 2018 correspondence, the appellant elaborated on her contention that the Veteran’s developed an acquired psychiatric disorder in service that caused or contributed to his death. She specifically asserted that the Veteran’s mental health problems, as well as controlled substances he utilized to deal with these symptoms, were causally linked to the cardiovascular and pulmonary disorders which caused or contributed to his death. The appellant included multiple citations to medical and scientific literature indicating support for her claims. In June 2020, the Board remanded the appeal with instructions for the Agency of Original Jurisdiction to obtain a medical opinion addressing the appellant’s arguments. (As noted above, the Board had reopened the claim following the issuance of a prior, final Board decision denying the claim in August 2004.) Such an opinion was provided by a VA physician in September 2020. In the September 2020 medical opinion, the VA physician first concluded that it was less likely than not that any of the medical problems documented in the Veteran’s service treatment records had any causal relationship to the diseases that caused or contributed to his death. Regarding the Veteran’s bout with rheumatic fever in service, the physician acknowledged that the condition was diagnosed and that the Veteran was hospitalized in January and February 1954. However, the physician noted that the Veteran was shown to recover “without any apparent long-term sequala.” The physician continued: “Specifically, there is no evidence of a cardiac condition arising secondary to the rheumatic fever. The veteran served an additional three years without any evidence of cardiac disease or sequela of rheumatic fever.” The physician referenced the articles submitted by the appellant “detailing potential effects of rheumatic fever,” which the physician deemed “essentially correct.” However, the physician found that there was absolutely no evidence the veteran manifested any of these potential complications. The most common presentation for cardiac involvement would have been a murmur of the mitral valve. There is no evidence at the end of service in 1957 or upon return to service in 1970. Clearly, the veteran had no evidence of complications of rheumatic fever 16 years after the event. Therefore, it is less likely than not that the veteran’s rheumatic fever, which was acute and self-limited, without evidence of long-term consequences while in service, or proximate to service after 1970, contributed in any way to the veteran’s death. This includes the cardiac collapse, which was almost certainly due to the respiratory collapse due to pneumonia, and likely sepsis. The VA physician further determined that there was “no evidence of a chronic respiratory condition while in service.” The physician acknowledged that the Veteran had “episodic bronchitis” in service but found that this was acute and self-limited. Notably, separation documents in 1957 and at reentry in 1970 were negative for a chronic respiratory condition; the physician noted that the veteran would not have been a candidate for reentry into service with a chronic lung condition or a post-rheumatic cardiac complication. Therefore, it is less likely than not that the veteran’s acute, isolated, self-limited respiratory infections in service played any role in the veteran’s COPD and subsequent causes of death. Concerning the possibility of asbestos exposure, the VA physician opined that there was “no evidence of toxic exposure causing lung disease while in service,” stating the above rationale also applied to these contentions; the physician explained that “[a]ny respiratory condition or cardiac condition arising due to said exposures would almost certainly manifest at the time of such exposures or proximate to them.” As noted above, this did not happen in the Veteran’s case. Rather, the physician concluded, “the veteran’s 30+ pack-yr smoking history is most likely cause of his respiratory condition, leading to his ultimate demise.” The physician further stated that headaches did not cause the Veteran’s respiratory conditions leading to his death. The physician stated that his confidence level for all the opinions provided was greater than 99 percent. Regarding the appellant’s arguments concerning the Veteran’s mental health history being linked to his death, the physician opined that there was “no physiologic or anatomic mechanism by which the veteran’s claimed psychological condition could cause or impact the veteran’s cause of death. There is absolutely no medical evidence to support such a claim.” Thus, it was “unlikely that the veteran’s claimed psychological condition contributed in any way to the veteran’s demise.” In October 2020, the appellant submitted another statement reiterating her belief that the Veteran’s mental health problems began in service and subsequently led to the development of the medical conditions which caused his death. The appellant submitted correspondence later that month indicating that she planned to submit additional evidence and requesting that VA wait 30 days to decide her claim. Since then, she has not submitted any new evidence. After careful review, the Board finds that the weight of the evidence is against any causal link between the causes of the Veteran’s death and his active service. Initially, the probative evidence reflects that the Veteran’s chronic cardiovascular and pulmonary disorders first developed many years after his discharge from service. As illustrated above, the Veteran’s medical records show that he first developed chronic lung problems, including COPD and emphysema, in the late 1970s, and chronic cardiovascular problems even later. The Veteran’s service treatment records include references to the occasional cold, acute bronchitis, and headaches, but there is no mention of the cardiovascular or pulmonary conditions that would later be deemed the causes of his death. Moreover, the September 2020 VA physician’s opinion demonstrates that there is no persuasive evidence that any chronic cardiovascular or pulmonary disorders developed in service, or indeed for many years thereafter. This opinion is based on a detailed review of the facts of the Veteran’s case and has not been called into question by any competent medical analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008) (the probative value of a medical opinion is derived from factually accurate, fully articulated, and sound reasoning). The appellant is certainly correct that the Veteran was treated for rheumatic fever in service. Likewise, the Board has reviewed the medical articles submitted by the appellant pertaining to the long-term effects of rheumatic fever in some cases. However, the Board finds the September 2020 VA physician’s opinion to be the most probative evidence on this point, establishing that the Veteran’s episode of rheumatic fever resolved and was not shown to have any long-term effects or sequelae. Notably, the examiner reviewed the articles provided by the appellant, finding that while they were correct they were general in nature and insufficient to establish a nexus in the Veteran’s particular case, in light of the absence of long-term symptoms or other indications of chronic disease. The examiner found, based on the record, that there was no evidence of heart or organ damage caused by the Veteran’s rheumatic fever, and thus no evidence of a link between that episode and the cardiovascular or pulmonary problems that caused or contributed to his death. The Board again finds the September 2020 VA physician’s opinion to be the most probative evidence on this question. See id. The Board notes that the appellant raised the issue of chronic myelogenous leukemia being related to the Veteran’s service, to include his in-service episode of rheumatic fever. In this regard, as noted above, the medical evidence of record shows that the Veteran was not actually diagnosed with leukemia but rather with an intermittent leukemoid-type reaction. Furthermore, the death certificate does not indicate such a reaction was causally related to the Veteran’s death. Regardless, to the extent a leukemoid-type reaction may have caused or contributed to his death, the Board again finds the September 2020 VA physician’s opinion establishing no long-term damage resulting from the Veteran’s in-service episode of rheumatic fever to be highly probative. The appellant has asserted that the Veteran was exposed to asbestos during active service, to include while serving aboard the USS Kawishiwi while in the Navy. There is no specific statutory guidance with regard to asbestos-related claims, nor has the Secretary promulgated any regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) (DVB Circular) provides guidelines for considering compensation claims based on exposure to asbestos. The Court of Appeals for Veterans Claims (Court) has held that VA must analyze a claim of entitlement to service connection for asbestosis or asbestos-related disabilities under the administrative protocols of these guidelines. Ennis v. Brown, 4 Vet. App, 523, 527 (1993); McGinty v. Brown, 4 Vet. App. 428, 432 (1993). These guidelines note that inhalation of asbestos fibers can produce fibrosis and tumors, that the most common disease is interstitial pulmonary fibrosis (asbestosis), and that the fibers may also produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, cancers of the gastrointestinal tract, cancers of the larynx and pharynx, and cancers of the urogenital system (except the prostate). It is noted that persons with asbestos exposure have an increased incidence of bronchial, lung, pharyngolarygneal, gastrointestinal, and urogenital cancers, and that the risk of developing bronchial cancer is increased in current cigarette smokers who had asbestos exposure. Occupations that have been recognized as involving asbestos exposure include mining and milling, shipyard and insulation work, demolition of old buildings, construction, manufacture and servicing of friction products, such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, etc. High exposure to asbestos and a high prevalence of disease have been noted in insulation and shipyard workers. Here, there is no probative evidence to suggest that the Veteran was exposed to asbestos during his Navy service. There is likewise no presumption that he was exposed to asbestos merely because he served aboard a Naval ship. Dyment v. West, 13 Vet. App. 141 (1991), aff’d sub. nom Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); VAOPGCPREC 4-2000 (Apr. 13, 2000). Rather, the only references to asbestos exposure in this case are from after the Veteran’s service. The Board further notes that there is no radiographic evidence of parenchymal lung disease. While a March 1994 X-ray report indicated findings consistent with asbestosis, no other medical record shows any asbestos-related lung disease. Moreover, the September 2020 VA medical opinion states that if the Veteran’s respiratory disorder were the result of exposure to harmful substances in service, he almost certainly would have developed symptoms shortly after such exposure. In the Veteran’s case, as noted above, the first evidence of chronic lung disease (as opposed to acute symptoms) appeared many years after his separation from service. The weight of the evidence therefore shows that the Veteran’s chronic cardiovascular and pulmonary problems—the causes of his death as noted on the death certificate—all appeared many years after his separation from active service. The appellant has raised numerous theories in support of her claim for service connection for the cause of the Veteran’s death; however, she has not put forth competent evidence establishing a relationship between any of the conditions associated with the Veteran’s cause of death and any symptom or diagnosis in active service. The Board is aware that in certain instances lay evidence, when competent, can establish a nexus between the Veteran’s death and an in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, however, the appellant is not competent to substantiate her contentions, as her claims involve complex questions of medical etiology. See 38 C.F.R. § 3.159(a)(2) (“Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience.”). Even assuming there is some truth in the appellant’s assertion that the Veteran suffered from mental health problems that were related to or exacerbated by in-service experiences, the Board finds that there is no competent evidence of record demonstrating a causal link between the Veteran’s mental health symptoms and the development of the chronic cardiovascular and pulmonary problems that caused his death. The Board cannot ignore the findings presented in the September 2020 VA physician’s opinion, in which the physician determined that there is no demonstrated biological link between the Veteran’s mental health problems and the conditions that caused his death. The Board is sympathetic to the appellant’s situation, and acknowledges the fact that the Veteran may well have experienced mental health problems that stemmed from his experiences in service. However, there is simply no probative evidence to establish a nexus between any acquired psychiatric disorder and the causes of the Veteran’s death. The Board is aware that the evidence indicates the Veteran’s long history of cigarette smoking was a contributory cause of his death. Notwithstanding, service connection is expressly precluded for disability or death related to chronic tobacco use in service for all claims, such as the instant one, received after June 9, 1998. 38 U.S.C. § 1103; 38 C.F.R. § 3.300. As a result, the Veteran’s history of tobacco use cannot serve as the basis for an award of service connection. In sum, the Board finds that there is no probative lay or medical evidence of record to indicate that the causes of the Veteran’s death were in any way related to his periods of active service. Rather, the weight of the evidence demonstrates that the conditions involved in his death began many years after service and were not caused by any incident of service. There is no, furthermore, no probative evidence that chronic heart or lung pathology developed to a compensable degree within one year after the Veteran’s separation from service, nor does the record show a combination of manifestations sufficient to identify such pathology that persisted continuously since service. See 38 C.F.R. § 3.303(b); see Walker, supra. The Board acknowledges the appellant’s contentions. Although the Board is extremely sympathetic to the appellant’s situation, her claim must be denied. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Minot, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.