Patients waiting for operations in north Staffordshire have been ordered to stop smoking or risk not having surgery.
Smokers are given three months to stub out their habit before they can have non-urgent operations such as hip and knee replacements, ENT procedures or removal of varicose veins.
Even if they do not kick the habit, GPs can still refer them to hospital as long as the patient is aware of the increase risks of post-operative complications.
But Tony Bruce, chief executive of the North Stafford-shire Primary Care Trust which is implementing the policy, said: "This won't be applied across all operations, it's not a blanket policy, but there will be situations where doctors will have to make a decision whether a smoker is suitable for surgery or not."
Smokers of all ages have a peak-flow breath test to measure their lung capacity to assess if they need to stop smoking before having surgery.
The newly-formed trust, which has inherited £1.4 million debts from Staffordshire Moorlands and Newcastle-Under-Lyme PCTs, first introduced the policy in July. Emergency and urgent operations are not affected.
More than one in four adults (26 per cent) in the West Midlands region smoke, with Newcastle-under-Lyme (28 per cent) and Stoke-onTrent (33 per cent) having the highest prevalence.
Mr Bruce said he would rather spend money on 'stop smoking' sessions than pay for the extra bed days smokers have in hospital to recover.
He said: "People tend to stay in hospital longer if they smoke as they are more likely to develop complications, like chest or wound infections, and that's not a good experience for patients or the NHS.
"If they stop smoking they are referred on for surgery but if not they are referred back to their GP, who must outline the risks and complications they face as a smoker by having the operation.
"If after that they still want to go ahead, then the GP can send them to the hospital for their surgery."
Other trusts which have implemented similar protocols include Norfolk Primary Care Trust, which is trying to claw back money to address its £50 million deficit.
In 1993, a surgeon at Southampton General Hospital refused to carry out a triple heart-bypass on a patient after he admitted he was a smoker. John Gibson, of Alton, Hampshire, died ten months later from a heart attack, and his wife received £40,000 in compensation.
Neil Rafferty, of prosmoking lobby group Forest, described the introduction of such schemes as "blackmail."
"Smokers pay taxes like everyone else. Because of the very high duty on tobacco, they probably pay a lot more than the average person," he said.