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NEW ZEALAND MEDICAL JOURNAL What is of greater concern is the way in which your ndents have sought to obecttre the message of our paper. This is that patients in our study were unhappy about cliar hich had' inflated at 24~+ per annum. No amount of analysis o total fee: of GST or of general practitioner incomes wiL change ese facts. Nor will they be altered' by claims that patients have right to determine what they deem to be a fair and reasonable c t for medical care. Further. some o our correspondents imply that the purpose of our paper wu to c cise general practice and to bring general practitionen into disre ' te. This is not so. as will be seen from our provious article (ul on ' topic: The purpoae of the present article was not to denigrete e efforts of general'~practitioners but rather to bring to attention curnent public perception of the cost of their services. We woul hope that this evidence will contribute positively to policy atte ts to devise a fee structure which ensures that family doctors ve a fair return for their efforts while at the same time protecting tients from the current inflation in patient charges which has large been caused by the way in which the relationships between the tal fee and GMS are set. G2 I ~S 7r > 23 AUGUST 1989' proportion of smokers as nonsmokers. As argued at iength elsewhere 16-12~ this biaa can produce an artefactual association of a similar magnitude to the association ciaime&by Kawachi et aliftl to be due to passive smoking. Wells 121 correction for this bias was totally inadequate, failing to allow for the possibility of miscltssified current typical regular smokers, whereas a recrnt summary of data from large studies shows an average rate of about 4% lul. Although there is virtually no epidemiological data on risk in relation to workplace exposure to passive smoking. Kawachi et al (Il present estimates based on unjustified extrapolations from the spouse smoking estimates. which are themselves hopelessly biased. The authors present numbers of deaths with ranges, so giving the uninformed reader  spurious idea of accuracy. When one considers no major authority has yet concluded passive smoking causes IHD: it is difficult to see what usefulI meaning one can attach to the cited lower limits of 39 IHD deaths for spousali smoking and 62 for workplace exposure. Peter N' Lee (Mr);. PN' Lee Statistics and Computing Ltd., Cedar Road. Sutton, Surrey' SM2 5DA. UK. D M Fergusson. L J Horwood, F T Shannon., Christc Developme Christchurch h Child Study, pital. e", , F Dy _ i' Christch h. 1. Fargusan DM. B..uttw AL SAamoo FT. Maveal wud.esaoente pnmrry. Y.Nth tan NZM.d:J 1e61-9.-291'.a. Oeaths from lung canc.r and ischaemic heart disaase due to passive smoking in N.w Z.aland Kawachi, Pearce and Jackson )l,i estimate that passive smoking causes 273 deaths per year in New Zealand. 30 from lung cancer and 243 from ischaemic heart disease (IHDI. Some 65% of'these deaths are attributed to workplace ezposure, the rest to spousal smo{dng: Tbae estimates are sdentifically'unjustified. Too much weight is given to fragile epidemiological data, major sources of bias being totally underestimated. Too little weight is given to evidence that nonsmokers have very low exposure to tobacco smoke coIIStltuents.. The evidence that passive smoking increases risk of IHD is very unconvincing. The authors t1I'cite a meta•analysis by Wells 1z1ifor their estimate of risk in relation to spouse smoking. This is based on 7 studies, maay of which involve unacceptably small numbers of cases, eg, as low as two deaths in women married to never smoking husbands 136 The two studies with adequate numbers are both open to question. One of these ie the Japanese prospective study h•al Walls cited results from 17 years follow' up (6) which claimed' a ai,gnificant trend in IHD in relation to spouse smoking, but failed to m.ntioa that this finding significantly Ip <0.001) 'conflicted with an ear}ier report, based on 14 years follow up which claimed no association whatso.ver! The other is the Maryland prospective study pl Iwhich reported 34% and 24% increases in IHD in men and woman in relation to spouse smoking. This study has many featurea that we notawortby. It made no attempt to follow up paopl* moviog outside Washington County, thus missing large numben of deaths. It found no doee response relationahip. It failed to collect data on a whole raagp of possibly relevant confoundiisg factors. Tboae it did adjust for (Ylge, marital statua, ye.n of school, qualityy of housing) had' an enormous effect on rdative risk. changins estimates from 1.17 to 131 in - and fiam 0•66 to 1.24 m wnmed emphasising the fragility of the results. The evidence relating passive smoking to lunt eancer is mon extensive than for IHD. being based on 27 published studiea, not 13 as Kawachi et aI sutt!' WhiL there is an asaooatioo of spouse smoking to lung cancer risk that cannot plausibly be a:plai6ed by ixtblicatian bias. it cannot be reliably inferted this results from a causal effect of pusive smoking. In the first place, exposure of nonsmokars to smoke constituents is very low. Thus typical nonsmokers retain only about 0.01-0.029G of the amount of smoking related particuiates retained by a smoker (Tl. Furthermora, there are various sources of persistent bias in the epidemiology, a major one caused by misc1~--ificstioo of a 1. Kaw.e)u.1. Peoro NE. J.aiam RT Douhs bam hieg ueor and umwnc A..rtatrn dn" tcp..ev. amobea mliw 7r1.e4 tiZM.tl J 1969 102337-.0 2W.ti. AJ An.rum.u of aAutt.mortaAkty.te tb Uaet.dStatw fiompaaav..motu„6 Eevvaom.nv Idt.rnauod.l 11il6. 1.. 24945 3. G.Aaad C. B.r..uCmnm E. Su.~ L.t.1 Eftactu of pe.n- soaot- hrn dlr. mart.lny m om®oY~a Lvts. atL .moY.n. Am JEqd.md 1966. ,121.. y4}50 4 Hln.yama T Veo-.mdom~ -w of,hrry..aa4,s h.r..hu~r n.kof liusa cmt- a ttutlyhom Jipan Br M.dJ 1961.2a2..1156S. Hu.yama T l.un6 csner m Jap.n.ff.ee. of nutruon .ad p..u...mot'.- . Ic MiWI i M. Ca.n.. P: .d.. Luee c.eer ala aedm p.wretm K.. Yort V.r4y Cl.ar la•am•••_•, 1964 .: 17S% 6. Hdan. KJ. S.ndl. DP: Gem.meY C W. Ch. E. Howes mar mmn.a4ty to L+we ac6 ueatrs. Am J Epm.omi 19M. 1Zf:.l1SYJ. 7~ Arupdd A. St.Ata6 T. W.ekam J Y~ makam, IaY( cm~ naku flem .ayo.ttn to prrtuulitw tobaQO ®a4a. EortemmrIwmre.ue..l.1tQ7, 13. Mi26B. Lsa PN, P..arv. ®oktn6.ed 4w6 ~ Aam.cm a rwrlt of bu.'.Hua.a Tos.ea/' 1967. 6~ 51724 9. La PN. MisJS6raum of~y.haMt. mdPrv. aabo.. A.i.vrA of td. .vdaon. tntre.t+mal AucEUw of OantFamd'rd H.NthSuyp+.mst: H.GaOrr Sprmrrv+rla.., 1tie6: 10; lr PH An altarnaav- mcp----pmfor the uevaaG raY of ptn6 o.eet m na4mauYrs marrrE to amoi'as. !c Prry R. Itnt P'W. d. In6av aed .mtirt.r yu.4ty tsOm S.lar. 1 YlB. 1 YP56. 11. Laa Ph'. Pa...w ~a6. F.et or6cum' Prpe }r.ammmud .tCaLf.m oa Pe~et and Funue of ls6es Au Qw{ttr A.ad mBrvairLm Feen.ry It16. 1909 . 12 ~ 1- PN . Probi.m. mmtrpr.ueg pd.mroiopeal d&ta P.P.r Pe..mmaud at Ca1~ oaArrmant of IeAa~•~y- H..ed. 6.Id mH~ v Fetiru.ry1YY1: IM9. iled vasectomy A t ACC appeal case was published 'm the Otago Daily Timn and I it vary disturbing Isee Medicoiegal p 4531: This couple was a ca6apeosatioc aft,er the alleged fa0urs of a va..ctomy part t O•m-^' Hoepital in 1979. A.her this operation it took nine ths befon the sperm count was sero. Nearly five years later appellant•s wife fall pregnant. Tseee happanings can be eaaily lained in that tb. vasectomy was performed correctJy but the count took a long time to reach zero because the patiemt as alow to ej aculat. all the aperm from his body. Ttis u qufte seen. 'Ib pregnancy resulted from recanaalisation of tbe v dafeens and can occur once in about every 500 vasectomies.. Y 'te the above asplanaoaaa, anme other surgeon has stated it is standard medical practice to recommend a rapeat v after three or at the most four positive sperm tests after a v y. Judge Middletan has accepted this surYeoa..vid.ooe as and this psaad.d th. judge to allow the c-1aiia If the facta case an as I reed thtm in the Otago Daily T'uaee tben,then a clear miscartiage of justice. Compensation has bean wrmgfy awarded a docttr wrongly accused of negligenee. This case may set a f Qrec.deat. Tbe Accident Compansation Corpontion abould not allowed to accept this appeal dewion and' this case should a higher court .ar. -rr