Unpacking complexities surrounding tobacco control policy formulation and tobacco industry interference in South Africa: a qualitative study

South Africa (SA) used to be recognized as a committed leader in tobacco control (TC) having passed effective TC policies in the 1990s, but in recent years, it has been overtaken by other countries. While research suggests that the tobacco industry (TI) predominantly uses economic arguments to shape TC policy discussions in SA, TI tactics to influence policy formulation have not been examined in the peer-reviewed literature. In this study, we draw on three frameworks (health policy triangle, 'bit in the middle', and Policy Dystopia Model) and 20 interviews, supplemented with academic and 'grey' literature, to explore TC policy formulation in SA. We focus on SA's 2018 draft TC Bill, which as of January 2025 has not been adopted. We found that despite SA's commitment to protect TC policies from the TI's vested interests, as set out in Article 5.3 of the World Health Organization Framework Convention on Tobacco Control, TI actors interfered throughout the policy formulation process. Participants reported efforts to shape policy alternatives by influencing the impact assessment and generating favourable evidence. To influence deliberation, they lobbied policymakers. To advocate for their preferred outcome, they sought to shape public opinion through campaigns and built alliances, for example, with the non-tobacco business community. The identified strategies were consistent with those observed elsewhere. Some were tailored to the SA context characterised by political corruption, and sensitivity around race and the legacy of Apartheid, as well as rivalry between transnational corporations and local producers. Industry actors also sought to redirect attention to TC areas (illicit trade and taxation) not led by the health sector, likely more susceptible to TI influence. The study demonstrates to policymakers, advocates, and researchers, the importance of not looking at a TC policy in isolation and of being mindful of industry efforts to exploit inherent policy-making complexities.