The serious health risks associated with smoking tobacco have been too well established for too long to harbor any doubts about that link. On average, studies show, people who smoke die about 10 years earlier than those who do not. It’s the leading preventable cause of death. And smoking is linked to about 30% of all cancer deaths in the United States. As a result, virtually any public policy choice — from public education and outreach programs that warn against smoking to state laws banning tobacco sales to teens —can be relied upon to pay enormous public health dividends. Tobacco is linked to about 480,000 deaths in the U.S. each year. That is COVID-19 pandemic territory.

Yet sometimes, these choices can be tricky. One recent example was the decision by the U.S. Food and Drug Administration to, for the first time under its revised regulatory authority, authorize R.J. Reynolds to keep selling three of its Vuse vape products in the U.S. The FDA did not find that these e-cigarettes are safe, and the agency did not give them a stamp of approval. Rather, it recognized that vaping can help adults stop smoking. Switching to e-cigarettes from the real thing carries some health benefit, the FDA determined — although officials also pledged to remain “vigilant” against any effort to market them to nonsmokers, particularly to young people (and the agency did not approve flavored versions which tend to appeal to teens).

Here’s a similar quandary that specifically faces the Maryland General Assembly: Should people who smoke be required to pay more for their health insurance on the Maryland Health Exchange, the state’s insurance marketplace established in accordance with the Patient Protection and Affordable Care Act? Under federal law, Maryland is authorized to make this choice but does not do so currently, although most states do. Some insurance carriers want Maryland to change its rating system. That would require action by the legislature, a point made clear by the state’s insurance commissioner during a hearing on the matter last week by House Health and Government Operations Committee.

At first glance, this sounds appealing. After all, the higher rates would be justified as smokers use more health care. And raising rates for some would mean lowering it for others at a time when costs for most everything are going up. Raise health insurance rates by 5% for smokers, for example, and nonsmokers might see a 1% to 2% discount in premiums. Forcing smokers to pay more gives them one more incentive to quit, doesn’t it? That is, after all, one of the prime justifications for raising the tax on cigarettes which the General Assembly did by a whopping $1.75 per pack last year (and overriding Gov. Larry Hogan’s veto earlier this year to cause it to go into effect on March 14).

But here’s the problem. While raising prices can deter tobacco sales, it’s less effective on adults who are already addicted to smoking, and that circumstance falls disproportionately on low-income people, many of whom get insurance through the exchange. Thus, raising rates may have the unintended consequence of causing such individuals to drop insurance coverage. And who pays if they then fall seriously ill and require emergency care? That would ultimately be the taxpayers of this state.

That’s one reason why organizations like the American Cancer Society Cancer Action Network opposes smoker surcharges. Anti-cancer advocates aren’t going soft on tobacco, but they do recognize that dropping insurance coverage is problematic. Better to keep families covered by insurance and get smokers enrolled in cessation programs that are, ironically, covered by insurance.

That’s not to suggest higher tobacco taxes are wrong. They are not. But we would also concede that, as tax policy, they are regressive — their burden weighs more heavily on low income households. But that’s always been a reasonable trade-off if it means kids are deterred from buying costly cigarettes and not taking up the habit in the first place. Risking health insurance is simply the wrong place to draw the line.

Sadly, one of the COVID-19 pandemic’s side effects has been to halt to what had been a steady decline in cigarette sales nationally. Maryland has been part of that trend with tobacco tax collections rising in 2020 after falling near 5% the year before. And there’s also been a downturn in calls to smoking cessation hotlines across the country, likely because of increased depression, stress and isolation associated with the pandemic. But none of that argues for higher health insurance rates for smokers. Rather, it strongly suggests that smoking ought to be treated as a public health crisis with more done to help adults quit beyond making the habit more costly.

Baltimore Sun editorial writers offer opinions and analysis on news and issues relevant to readers. They operate separately from the newsroom.