Gendered Motivations for E-Cigarette Use Among Native Hawaiian and Pacific Islander Youth: A Relational–Cultural Perspective

Abstract

E-cigarette use among youth has become a significant public health issue, with Native Hawaiian and Pacific Islander (NHPI) youth exhibiting some of the highest usage rates in the United States. Despite the role of gender-specific motivations in shaping substance use behaviors, limited research has examined these dynamics within NHPI populations. This study explores the gendered influences on e-cigarette use and non-use among rural NHPI youth through data collected from 17 gender-specific focus groups (N = 69) conducted across eight public schools on Hawai‘i Island. Key findings revealed two distinct themes: girls emphasized relational harmony, basing their decisions on the impact to familial and peer relationships, while boys were primarily driven by individual goals, such as enhancing athletic performance and avoiding negative consequences. These insights underscore the necessity for culturally tailored, gender-specific prevention strategies that address the unique relational and individual factors affecting NHPI youth substance use behaviors.

Introduction

E-cigarette use among youth has become a significant public health concern in the United States, with Hawai‘i youth being particularly affected.¹ Nearly half of high school students and over 30% of middle school students in Hawai‘i have tried e-cigarettes, with higher rates among Native Hawaiian and Pacific Islander (NHPI) communities.^1–3 Among Native Hawaiian youth, girls face unique challenges and more severe substance abuse consequences than their male counterparts.^4–5 However, research on the gender-specific impacts of e-cigarette use among Native Hawaiian youth is limited. Addressing this gap is critical for creating culturally sensitive prevention strategies that effectively target gender differences among NHPI youth to mitigate the consequences of e-cigarette use among these youth.⁶

This study explores gender differences in e-cigarette use motivations among rural Native Hawaiian youth. Using relational–cultural theory (RCT) as a framework, it examines how culture- and gender-specific factors shape Hawaiian youths’ substance use behaviors. These findings support the need for culturally appropriate, gender-specific drug resistance training, thereby informing the development of effective substance abuse prevention programs for Native Hawaiian youth.

Understanding NHPI Gender Differences through Relational Cultural Theory

RCT is a psychological framework that highlights the role of interpersonal relationships in shaping an individual’s identity, behavior, and decision-making. The framework posits that forming meaningful connections is fundamental to human development, promoting well-being, belonging, and purpose.^7–8 Native Hawaiian adolescents are deeply influenced by interdependent relationships with their family and peers, which play a pivotal role in shaping their substance use behaviors.⁹ Compared to non-Hawaiian peers, they navigate decision-making within a broader relational network that includes both immediate and extended family members, reflecting the cultural emphasis on collective well-being and interconnectedness.¹⁰ Similar types of relational networks, and their influence on youths’ substance use behaviors, have been described for other Indigenous populations.¹¹ However, research indicates these relationships vary by gender.

Similar to other Indigenous youth populations, Native Hawaiian girls are often socialized to prioritize family and community well-being over their own. This can strongly influence their decision-making, especially within closely-knit rural communities. Refusing substance use offers from family or peers can be incredibly challenging and problematic for these girls, as such refusals disrupt critical social bonds central to their identity and sense of belonging.^12–13 While often protective, these relational networks can also increase substance use risk. When substance offers come from close family or peers, the cultural value of relational connectedness may lead girls to prioritize relationships over abstinence, heightening their vulnerability to substance use.^4,10,13

Conversely, Native Hawaiian boys are often socialized toward independence and individual achievement. They are more likely to focus on individualistic goals—such as athletic performance, personal success, or avoiding negative consequences—than Native Hawaiian girls. This focus on personal aspirations can outweigh relational influences, and affect their decision-making, as boys weigh the pros and cons of substance use.^14–15 These findings underscore the interplay between relational and individual motivations in shaping boys’ substance use behaviors. They also underscore the gendered nature of relational influences, emphasizing the need for culturally tailored approaches.

Relevance of the Study

Understanding gender differences in e-cigarette use motivations is crucial for developing culturally and gender-specific prevention strategies for rural Native Hawaiian youth. Traditional abstinence-based interventions often ignore relational dynamics central to NHPI communities, especially for girls. This study applies RCT to examine how culture- and gender-specific interactions shape substance use behaviors. It highlights the unique challenges Native Hawaiian girls face in balancing individual goals with the relational dynamics of close-knit communities. Findings emphasize the need for culturally relevant, gender-specific drug resistance training to address e-cigarette use and health disparities in NHPI communities.

Method

Data were collected in the first year of a multiyear study to inform the development of a culturally grounded, school-based e-cigarette prevention intervention for NHPI youth. We used qualitative methods to examine NHPI youths’ sociocultural context and demands to use e-cigarettes.¹⁶ Gender-specific focus groups were guided by a semi-structured interview schedule (see Table 1) approved by the Institutional Review Board at the University of Hawai‘i at Mānoa, protocol 2022–00225. Students who participated in the study were required to assent and provide active parental consent. The authorship team included Asian American (70%) and Native Hawaiian (30%) researchers with lived and/or professional experiences with rural NHPI schools and communities. This manuscript complies with the Standards for Reporting Qualitative Research.¹⁷

Table 1.

Semi-Structured Interview Schedule (Adapted from Helm & Okamoto⁵).

1. Have you or someone you know ever been offered e-cigarettes, something similar to e-cigarettes (like vape pens), or tobacco cigarettes? If so, what did you/they do?

2. Where do kids use e-cigarettes, similar devices, or tobacco cigarettes on Hawai‘i Island?

3. Have you or someone you know been invited to go with kids who planned to use e-cigarettes, similar devices, or tobacco cigarettes? What did you/they do?

4. Is it hard to resist offers to use e-cigarettes, similar devices, or tobacco cigarettes? Why or why not?

5. If your parents found out that you had been using e-cigarettes, similar devices, or tobacco cigarettes, what would they do?

6. How would you respond to your parents if they found out that you had been using e-cigarettes, similar devices, or tobacco cigarettes?

7. Do you know of anyone who uses both an e-cigarette or a similar device and tobacco cigarettes? Which type of cigarettes did they start to use first? Do they continue to use both of them? In what way(s)?

8. Have you or someone you know ever vaped marijuana or used tobacco products other than e-cigarettes or tobacco cigarettes (e.g., chewing tobacco, hookah, or pipe)? Please describe.

Sampling and Participants

Sixty-nine youth were recruited from 8 elementary, middle, intermediate, or multi-level Hawai‘i Island public schools. These schools were selected based on their geographic dispersion and their high concentrations of Native Hawaiian and Pacific Islander students. Students participated in one of 17 gender-specific focus groups. The mean percentage of Native Hawaiian or part-Hawaiian students across public schools in our sample was 34% (SD = 5.8). The sampled schools served youth and families who resided in low-income and/or rural communities. School-based research liaisons (e.g., teachers, counselors) informed their schools and students about the study and recruited NHPI students in three categories: e-cigarette users, non-users, and contemplators (i.e., those considering use).The liaisons helped to identify youths in their schools across the three categories who were verbal and willing to discuss offers to use substances in a group setting. Sample demographics are in Table 2.

Table 2.

Participant Demographics (N=69).

	Variable	M	SD	%
Gender
	Male			48.0
	Female			42.0
	Non-Binary			9.0
Age		12.5	0.59
Grade
	7th			65.0
	6th			25.0
	8th			3.0
Ethnicity
	Hawaiian/Part Hawaiian			58.0
	Multiracial (excluding part-Hawaiian or part-Pacific Islander)			10.0
	Other Pacific Islander			9.0
	White			9.0
	Hispanic/Latino/Spanish			7.0
	Filipino			6.0
	Japanese			1.0
Vaping History
	Vaped Before			38.0
	Interest in Vaping			21.0

Procedures

Focus groups occurred in a private room on participating schools’ campuses. Each participant joined a gender-specific focus group facilitated by a doctoral-level researcher and observed by a notetaker. No teachers or school staff were present during the focus groups. Facilitators used a semi-structured interview schedule to guide discussions on e-cigarette use in homes, schools, and communities (see Table 1). Notetakers documented non-verbal communication and participant behaviors to enhance transcription accuracy. Focus groups lasted 45–60 minutes, and participants used pseudonyms for confidentiality. Students received a $5 gift card and snacks for their participation.

Data Analysis

Focus group discussions were audio-recorded, transcribed verbatim by a research team member, and verified by a different team member. An inductive coding approach informed by grounded theory was used to identify emergent themes.¹⁸ To establish a coding framework, five research team members coded one male and one female focus group transcript. Once open codes and their definitions were finalized, transcripts were coded individually and validated in pairs. Hierarchical relationships between codes and overarching themes were developed through axial and selective coding, respectively. Inter-coder reliability was established through consensus coding, rather than calculating numerical concordance among coders. Discrepancies in the coded narrative segments between team members were discussed until consensus was reached on the inclusion or exclusion of the segments within the data set. Data saturation was determined when no new themes emerged from focus groups conducted later in the data collection process. The peer pressure code was examined, and gender differences were identified and analyzed within this code. Data was managed through a computer-assisted data analysis software program (NVivo 14).¹⁹

Results

Girls’ Focus Groups

The data from the girls’ focus group suggested that they prioritized preserving interpersonal relationships and maintaining social harmony when faced with vaping offers. Their responses to vaping offers depended on their relationship with the offeror and the other relational expectations they believed they needed to preserve. While interactions between vapers and non-vapers were largely non-confrontational, some experienced subtle pressure from repeated offers, and social circles often formed based on vaping behaviors.

Preserving Interpersonal Relationships

When faced with e-cigarette vaping offers, girls strongly considered the relational consequences of accepting or refusing the offer. Their decision to accept or refuse was influenced by the perceived impact on their relationship with the offeror. Participant “Frost” describes the difficulty of refusing a vaping offer when the offeror is a close friend. Having previously lost a friendship for refusing to vape, she expresses concern that declining another offer could jeopardize her existing friendships.

What would make it harder [is] if they’re my best friend, I just don’t want to lose our connections to each other because I already lost one.

“Rihanna,” another participant from the same focus group, concurred with “Frost,” stating that losing friends was her primary concern when rejecting a vaping offer. Participant “Indigo” clarifies that rejecting a vaping offer is dependent on “who the person [offeror] is.” Participant Indigo differentiated the relationship between a “best friend” or “just a friend.”

Furthermore, in addition to considering the relational implications of declining a peer’s offer, girls also noted the potential impact on familial relationships when making vaping or non-vaping decisions. They reported parental or grandparental influences as reasons for refusing vaping offers. Participant “Betty” elaborates on her decision to decline a vaping offer.

I said no [to a vaping offer] because I was thinking of doing it, but I decided not to because of my parents. But it was really like very much pressure.

Additionally, Participant “Dory” explained,

[I] was offered [a vaping device] in school one time, [and] I told them no [because] my parents would get really mad.

Five other participants - “Rihanna,” “Frost,” “Buffy,” “Princess,” and “Ripley”- reinforced similar reasons for refusal, stating that their parents and grandparents “would be upset” and “would not be happy.”

Preserving Peer Social Harmony

Participants described interactions between vapers and non-vapers as generally non-confrontational, emphasizing the importance of maintaining group cohesion. Many reported that while friends who vaped occasionally offered them vapes, a simple refusal was usually sufficient to stop further offers. Participant “Diva” explained,

A lot of the times, the people I surround myself with, they’re really understanding. They really don’t pressure you. You’ll be in the bathroom with them but just sit in. And then they pull out [a vape] and then [take a] hit [on] it and then [say], ‘You want?’ A lot of the times for me, I just say, ‘No, I don’t do that anymore.’ They’re just like, ‘Okay, yeah.’

Similarly, participants “Orchid” and “Buffy” described vaping as an optional behavior in mixed-group settings, with vapers and non-vapers expressing that participation was a personal choice.

Facilitator: Now, if we think about people vaping in a group, and say you were in a group of people who were vaping, would everybody in the group be expected to vape, or could you choose whether to participate?

Buffy: You could choose to.

Facilitator: Okay, you could choose to. That was Buffy’s experience. Anyone else?

Orchid: Same with Buffy, you can choose.

Facilitator: Okay, so it’s not a strong peer pressure situation.

Orchid: Mhm [agrees].

Buffy: No. ‘Cause they tell me like, ‘You don’t have to do it and stuff,’ and they’re like ‘If you don’t want to, it’s fine.’

Similarly, Participant “Princess” stated that in group settings, individuals could “[vape] if you wanted to, but if you didn’t want to, you didn’t have to.” Participant “Ripley” reinforced this perspective, stating, “you can choose in the group.”

While participants felt their friends respected their decisions not to vape, many experienced pressure from repeated offers. Participants “Indigo,” “Gecko,” “Gamora,” and “DW” stated that friends who vaped “respect their decision not to vape.” However, while participants noted that their friends accepted an initial refusal, they encountered pressure from repeated offers by the same individuals. Participant “Gamora” stated, “Yeah, I said no many times,” while Participant “DW” noted, “I declined multiple times.” Participants “Indigo” and “Gecko” agreed they had similar experiences. Additionally, Participants “Coral,” “Gabs,” and “Queen” stated that while they can say no to their friends, they expected more offers in the future from their friends as they get older, moving from “7th grade to 8th grade.”

Lastly, participants noted that while interactions between vapers and non-vapers were largely harmonious, social circles tended to form based on vaping behavior. Participant “Pixie” observed that “more than half of the time,” individuals who do not use e-cigarettes tend to associate with one another, while those who use e-cigarettes typically form social groups with others who vape. Similarly, participants “Coral” and “Karma” stated that “most [who] vape together hang out with other people who do it.” Participant “Frost” acknowledged that groups with vapers and non-vapers can “still be friends” but noted that it is more common for non-vapers to hang out with non-vapers and vapers to hang out with vapers.

Boys’ Focus Groups

One theme that emerged from the boys’ focus group findings indicated that, when faced with vaping offers, boys often prioritized their individual goals. They emphasized their pursuit of their personal interests and avoiding personal consequences.

Pursuing Personal Interests

When faced with vaping offers, boys often prioritized their own goals and well-being. For example, Participant “Phoenix” emphasized the connection between avoiding vaping and athletic participation, stating, “don’t do it [vaping] or else you’re going to not be able to play sports.” Similarly, “Flash” noted that boys who reject vaping offers are often motivated by their interest in sports. These perspectives align with those of “Cyclops,” who explained that his decision to refuse vaping was influenced most by his own personal goals and athletic performance.

Facilitator: How are you going to stay friends with him but make sure he knows that you don’t want to use it anymore? How are you going to communicate that to him?

Cyclops: I’m just going to tell him “no”. Before I didn’t have a reason, but I’m trying to get to somewhere now, so I can’t [keep] doing that stuff, you know. I’m trying to do a lot of sports and I go to the gym, so I need all the energy I can get. So, I can’t [vape]. And we run, like, a lot, and we do a lot of things, and then I got to sign up for wrestling later. I [also] do basketball, so I can’t [vape].

Avoiding Personal Consequences

Male participants frequently emphasized negative consequences as significant factors in their decision regarding vaping. For example, “Pluto” highlighted the risk of suspension as a major deterrent to vaping.

Yeah. Every time I saw it [a vape], oh I just wanted to grab it. Then I stopped ‘cause I know that if I kept doing it then I would get in trouble.

Three other participants, “Tupac,” “Tsunami,” and “Phoenix,” validated similar personal consequences, stating that “there’s cameras on the bus too, that’s why I don’t smoke” and “no one wants to get snitched on.” Participants “Jax,” “Flash,” “Subzero,” and “Beast” described frequent vapers as kids “that would be breaking some rules” and as“troublemakers” who “always get in trouble” and are “suspended for getting caught.”

Discussion

This study examines gender differences in motivations for e-cigarette use and nonuse among rural Hawaiian youth. An analysis of participant responses during focus group interviews revealed distinct gender differences in these motivations. Specifically, male participants were primarily motivated by the desire to protect their individual goals and interests, with less concern for the relational consequences of e-cigarette use. Their focus was on how negative outcomes, such as health consequences or suspensions, could hinder their personal goals and well-being. Therefore, it is important that anti-vaping interventions, such as rules, guidelines, and e-cigarette prevention education, highlight the potential negative consequences for boys. Conversely, consistent with the principles of RCT, female participants were strongly motivated by the desire to preserve and safeguard their existing relationships when deciding whether to accept or refuse a vaping offer.

The focus groups revealed two primary themes underlying female motivations for e-cigarette use: 1) preserving interpersonal relationships and 2) maintaining social harmony within their peer groups. Female participants considered the long-term relational consequences of their actions, particularly how these actions would impact their relationships with friends and family. In some cases, this emphasis on relationships influenced their engagement with peers who vape, as maintaining social cohesion took precedence over personal stance on vaping. While they may not explicitly acknowledge peer influence, their future vaping decisions are shaped by prevailing attitudes and behaviors within their immediate social networks. This suggests that for NHPI girls, the degree to which their social environments reinforce anti-vaping attitudes could play a critical role, given their heightened awareness of relational consequences.

While the relational influences described by girls in this study would most likely transfer to urban NHPI youth or those on the Continental U.S., the degree to which they would impact their use of refusal strategies could differ from the rural NHPI youth in the present study. Past research on rural NHPI youth in Hawai‘i described how youths’ decisions to use substances are strongly influenced by interconnected relational networks of extended families within close-knit communities.²⁰ The absence of this dynamic in urban NHPI youth or those on the Continental U.S. would most likely lessen the overall impact of relational considerations in decisions to accept e-cigarette offers for these youth. This, in turn, could impact the effectiveness of gender-specific e-cigarette prevention interventions developed for rural NHPI youth when used with urban NHPI youth or those on the Continental U.S.

Implications for Substance Use Interventions

Examining gender differences in preferred drug resistance strategies has implications for developing and implementing culturally and developmentally appropriate, gender-specific resistance skills training for rural Hawaiian youths. Drug prevention interventions that solely meet individualistic goals regarding abstinence (e.g., “just say no”) may be ineffective for NHPI girls, as they overlook the cultural and gender-specific relational pressures and consequences of substance use decisions. Thus, as RCT suggests, practical drug resistance skills must balance the goals of relational connectedness and drug abstinence, especially for NHPI girls in close-knit rural communities. Moreover, gender- and culture-specific drug prevention strategies should be more contextual and relational, recognizing the complexity of these dynamics. As girls in our study were more attuned to social relationships and consequences, the findings suggest that prevention programs for NHPI girls should balance e-cigarette abstinence with relational harmony, and that programs focused solely on individual goals may be less effective for them.

More broadly, our findings suggest that resistance skills training should be tailored to address the distinct needs of NHPI boys and girls. For boys, training could focus on assertive, individualistic strategies, such as confidently saying “no” to e-cigarette offers or emphasizing the personal consequences of prolonged use. In contrast, strategies for girls should be designed to help them navigate peer pressure while preserving relationships. This could include techniques such as using humor, suggesting alternative activities, or redirecting conversations to deflect peer e-cigarette offers. These approaches could serve as the foundation for gender-specific modules that can be integrated into school- or community-based health curricula and/or programming. By incorporating these culturally and gender-specific approaches, prevention programs can equip both NHPI girls and boys with effective resistance skills that align with their relational and individual priorities.

Study Limitations

The students’ responses in the focus groups may not fully represent their true perspectives and experiences. The focus group setting could have discouraged participants from sharing openly due to fear of peer judgment or potential negative repercussions. Further, due to logistical considerations, member checking with student participants was not conducted in this study. Selection bias may have occurred due to the requirement for active parental consent, as some parents may have withheld consent to prevent their child’s experiences from being documented. The small sample size of gender-nonconforming students also resulted in their exclusion from both the coding and analysis. Recent studies have found that LGBTQ+ youth have shown higher rates of e-cigarette use and may shed light on other gender-based motivations.^21–22 Thus, future research should focus on examining e-cigarette resistance strategies for gender-diverse youth. Lastly, the geographic specificity of this data limits its applicability to rural Native Hawaiian or Pacific Islander youth on other islands of Hawai‘i or in the Continental U.S.

Conclusion

This study contributes to the limited research on gender differences in substance use among NHPI youth by examining how they manage e-cigarette offers. The findings, grounded in RCT, underscore the importance of addressing relational contexts in NHPI populations. Specifically, future interventions for NHPI girls should prioritize preserving interpersonal harmony, while those for NHPI boys should emphasize individual incentives and consequences to resist e-cigarette use. Further research should explore the complexity of NHPI girls’ relational connectedness in e-cigarette-related situations to deepen understanding of gender influences. To enhance effectiveness, prevention efforts targeting rural NHPI communities should incorporate gender-specific content to enhance substance use prevention efficacy and effectiveness.

What we already know:

• E-cigarette use among youth is a growing public health concern, especially in Hawai‘i, as Native Hawaiian and Pacific Islander (NHPI) youth report disproportionately higher usage rates compared to other ethnic groups.

• Relational networks, such as familial and peer relationships, play a significant role in substance use behaviors among Native Hawaiian adolescents, with gendered differences influencing these dynamics.

• Traditional prevention strategies fail to address the unique relational and cultural factors that influence NHPI youths’ decisions to use substances, especially the gendered differences between NHPI boys and girls.

What this article adds:

• This study highlights the gender-specific motivations that influence e-cigarette use decisions among rural NHPI youth.

• It underscores the importance of culturally tailored and gender-specific prevention strategies that target specific aspects of NHPI communities.

• Utilizing the relational-cultural theory framework, the study provides new insights into how cultural and gender-specific factors influence substance use, offering guidance for more effective and culturally grounded interventions for NHPI youth.

Data Availability Statement:

Deidentified raw data supporting the conclusions of this article will be made available by the authors on request.