Background:
Electronic Nicotine Delivery Systems (ENDS) - e-cigarettes and e-hookahs and traditional products like hookah, revamped in attractive forms, have garnered wide popularity in India, particularly among young people. Without a national legislation to regulate these products, the tobacco industry has spearheaded surreptitious promotional campaigns to market these products, exploiting gullible consumers. This qualitative study aimed to gauge perceptions of multiple stakeholders (students, parents and teachers) on ENDS and hookah, underscoring the urgent need for regulating these products, which are circumventing the current inadequate regulatory framework.

Methods:
Eleven Focus Group Discussions (FGDs) were conducted with 102 respondents [school students, 12-15 years (19), teachers (15), parents (37) and college students, 18-25 years (31)], using a standardised FGD guide. The intent was to gauge perceptions/knowledge about use of and access to ENDS and hookah, among youth. Thematic issues explored included: information and knowledge gaps around constituents/harmful effects; accessibility and affordability; characteristics; mis-leading claims ['non-tobacco'/herbal (hookah)]; marketing/advertising; possible regulatory mechanisms etc. FGDs were audio-recorded and transcribed for qualitative analysis using ATLAS.Ti (version 6.2).

Results:
Gross mis-information and myths existed about ENDS and regular hookahs, being non-tobacco or non-nicotine products, which are safe or less hazardous/addictive than regular tobacco products, particularly cigarettes. High popularity, social acceptance, convenient availability and easy affordability were reported, particularly by students. College students were most updated about recent trends, followed by school students, teachers and parents (least aware). All schools visited, reported cases of ENDS confiscation/search. Widespread exposure to promotional campaigns was reported, maximally on e-commerce sites. All respondents stressed on the need of a comprehensive and nation-wide regulation on ENDS and hookah, similar to other tobacco products.

Conclusions:
There is an urgent need for progressive regulation/prohibition on ENDS and hookah under the Indian tobacco control law/other applicable legislation, for strengthening the implementation of the Framework Convention on Tobacco Control (FCTC), in India.