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Washington's failure to aggressively attack the high cost of smoking-related disease has long been unconscionable. It may soon be unaffordable.

President Obama has made clear that he intends to move forward this year with his proposal to vastly expand access to health insurance. Although few people in Washington now see the connection, that drive may lead the federal government toward a more serious effort to snuff out smoking, especially among young people.

The states with the most smokers have been the least likely to act.

Here's why: Any universal coverage plan will grow unsustainably expensive unless health care inflation slows. Preventing, rather than treating, disease is one key to controlling health care costs. And few diseases present a more obvious target for prevention than the heart and lung ailments and cancers linked to smoking. Rep. Henry Waxman, D-Calif., chairman of the Energy and Commerce Committee, says that as Congress considers universal health care it has "a greater incentive" to deal with tobacco because it is "a leading cause of preventable death and disease."

Washington's interest in combating smoking has flickered lately. Under President Clinton, the Food and Drug Administration asserted authority to regulate tobacco products. But the Supreme Court rejected that claim in 2000, and legislation to explicitly authorize FDA oversight languished during the Bush years.

To some extent, states filled that vacuum. Nearly half the states, for instance, have passed "smoke-free" laws limiting smoking in workplaces, public places, or both. But the effect of the state initiatives has been dulled by what might be called the tobacco paradox. The states that have moved the most forcefully against tobacco are those with the fewest smokers; the states with the most smokers have been least likely to act.

That trend reverberates through the scorecard on state tobacco policies that the American Lung Association published last month. Of the 15 states with the highest proportion of smokers in the adult population, 10 received an F on smoke-free laws; just three received an A or a B. By contrast, 15 of the 18 states with the smallest percentage of adult smokers received an A on smoke-free laws.

Fewer states received the association's top grades for raising cigarette prices through taxes, which studies show can discourage smoking. But the same pattern held. Ten of the 18 states with the fewest smokers received an A or a B on tobacco taxes; 13 of the 15 states with the most smokers received a D or an F. Almost all the high-smoking states flunked on smoking-prevention and -cessation programs.

In this pattern, it's difficult to say "which is the chicken and which is the egg," as Paul Billings, the lung association's vice president for national policy, puts it. The high-prevalence states may fail to act for fear of antagonizing their many smokers; or they may have so many smokers because they have failed to act. It also matters that the heaviest-smoking states are nearly all Republican-leaning red states generally dubious of regulation. Almost all of the lowest-smoking states are Democratic-leaning and more open to it.

Regardless of the explanation, this pattern produces inaction in the states that most need it. That increases the costs to taxpayers elsewhere for treating smoking-related disease under Medicare and Medicaid. In a universal health care system, those costs might soar.

That prospect strengthens the case for federal action. Congress took one significant step when it recently increased federal tobacco taxes by 62 cents a pack to fund expanded health care coverage for uninsured children. Even more important, Waxman plans to soon reintroduce legislation establishing FDA jurisdiction over tobacco products; the FDA couldn't ban them, but it could require further health-risk disclosure, reduce nicotine levels, and more tightly regulate marketing, especially to minors. Although the House comfortably cleared the bill last year, the Senate never considered it. Bush's opposition discouraged action; Obama, as a senator, co-sponsored the bill.

Even if the FDA legislation passes, Washington eventually may need to ponder other steps to reduce smoking-related disease--from mandating that states and private insurers fund cessation programs to exploring, either through legislation or occupational-safety regulations, a national ban on smoking in public places and workplaces.

Fiscal strains are now forcing even some of the most recalcitrant states to consider raising tobacco taxes. But the tobacco paradox ensures that only Washington can comprehensively confront the intolerable human and financial costs of smoking.