Factors That Influence The Decision To Vape Among

Struik et al.
BMC Public Health (2022) 22:641

https://doi.org/10.1186/s12889-022-13095-y
RESEARCH Open Access
Factors that influence the decision to vape

among Indigenous youth
Laura L. Struik1*, Saige‑Taylor Werstuik2, Alyssa Sundstrom2, Sarah Dow‑Fleisner1 and Shelly Ben‑David1
Abstract
Background: The use of e-cigarettes (vaping) among Indigenous youth is much higher than that of their non-
Indigenous counterparts, which has raised the concerns of various Indigenous scholars and communities. To better
understand the most salient constructs that influence Indigenous youth decision-making around vaping, we co-
created a qualitative research study with a Syilx First Nation community that was guided by the Unified Theory of
Behavior (UTB).
Methods: Through semi-structured interviews and a sharing circle, we gathered the perspectives and experiences
of 16 Syilx youth in British Columbia, Canada. After an initial collaborative coding and training session, the interviews
were transcribed and coded by Indigenous peer researchers using Nvivo. Through both directed and conventional
qualitative content analysis methods, the final conceptual framework was collaboratively developed.
Results: Syilx youth reported that vaping decision-making is underpinned by colonialism, and the historical dis‑
proportionate impact of the tobacco industry. The youth spoke to several individual determinants that influence
intentions to vape (e.g., vaping helps you cope) and to not vape (e.g., family and community connectedness), and
determinants that translate intentions to vape to decision to vape (e.g., access to vaping), and to not vape (e.g., access
to trusted adults and support from the band). The youth suggested that prevention efforts must be informed by an
understanding of why Indigenous youth vape and what strengthens their resolve to not vape.
Conclusions: Vaping decision-making among Indigenous youth is underpinned by their cultures, contexts, and
histories. To effectively address vaping among Indigenous youth, continued engagement of Indigenous youth in
planning, developing, implementing, and evaluating both prevention and policies efforts is a necessity.
Keywords: E-cigarettes, Indigenous youth, Qualitative research
Introduction 20–24 share similar statistics with past 30-day use and
Background ever trying at 13 and 43% respectively, adults over the age
Youth have been the primary target for tobacco alterna- of 25 had significantly lower rates, at 3 and 13% respec-
tives, particularly e-cigarettes [1], which is underscored tively [2]. Additionally concerning is emerging evidence
by their high rates of use. In 2020, 14% of Canadian youth that Indigenous populations of youth in North America
ages 15–19 vaped in the past 30 days, and over a third have higher usage rates and are at higher risk for e-ciga-
(35%) reported ever trying it [2]. While young adults ages rette use compared to their non-Indigenous counterparts
[3, 4]. For example, in a study that examined e-cigarette
behaviour among a national sample of over 14,000 youth
*Correspondence: [email protected]; [email protected]
1
in the United States, the authors found that compared to
Faculty of Health and Social Development, School of Nursing, The
University of British Columbia, Okanagan Campus, Syilx Okanagan Nation non-Indigenous youth, American Indian/Alaska Native
Territory, 1147 Research Road ART 140, Kelowna, BC V1V1V7, Canada students had the highest prevalence rates among dual
Full list of author information is available at the end of the article users (using both combustible cigarettes and e-cigarettes)
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Struik et al. BMC Public Health (2022) 22:641 Page 2 of 10
(16.2%) (RR: 2.10), and e-cigarette only users (11.3%) Indigenous voices and methods of data collection and
(RR: 1.70) [3]. Researchers in British Columbia, Canada, interpretation to build strength and resiliency through
examined vaping across five communities and stated that health promotion efforts, including tobacco control
vaping was found to be a significant issue in all of these efforts, in the community [18]. In order to develop
communities [4]. Given that youth vaping is associated meaningful and tailored e-cigarette prevention initia-
with increased risk for tobacco and other substance use, tives for Indigenous youth, it is essential to first explore
mental health problems, pulmonary and cardiovascular the unique factors that underpin their decision-making
disease, and unintentional injuries [5], Indigenous youth as it pertains to vaping, and their preferences for how
are vulnerable to these adverse outcomes at a larger scale. these factors are addressed, which is the aim of this
Indigenous populations continue to be a target by the study.
tobacco industry for using tobacco alternatives, includ-
ing e-cigarettes [4, 6, 7]. The disproportionate tobacco
use and tobacco marketing towards Indigenous people Conceptual framework
can be viewed as colonization [4]. Colonization is the Given the relationship between colonization and tobacco
process of the assimilation of a people forced to adapt to use among Indigenous youth, and the importance of cul-
the social, economic, and political protocols of a sover- ture to promote resiliency and positive health behav-
eign nation [8]. From an Indigenous perspective, coloni- iors, this work is grounded in a culturally responsive
zation has been implemented through land displacement, approach. A culturally responsive approach prioritizes
resource extraction, assimilation, cultural appropriation co-creation of knowledge development, and asking
and other aspects [9]. While some Indigenous groups use reflexive questions like, “How do the participants’ social
traditional tobacco for cultural ceremonies, this has been and cultural identities inform their unique communica-
misappropriated by the tobacco industry through use of tion practices that must be acknowledged within this
cultural imagery and concepts when marketing commer- research?” [20]. In this study, the research plans, imple-
cial tobacco [10], lending to significantly higher rates of mentation, and interpretations were co-created with two
tobacco use among Indigenous populations, including trained Indigenous peer researchers (SW and AS) (both
youth. leaders at their First Nation community youth center).
Indigenous people and scholars have been increasingly In this regard, Indigenous youth culture underpinned
raising concerns around the tobacco industry’s purposeful the research protocols and plans. Given that the focus
interest in appropriating Indigenous people’s names and of this research was to understand decision-making
imagery to further tobacco sales and profits [4, 7, 11, 12]. As around vaping among Indigenous youth, we employed
a result, leading Indigenous scholars have recently rejected Unified Theory of Behavior to develop a theoretical and
support from the Phillip Morris-funded Foundation for a evidence-based understanding of vaping among Indig-
Smoke-Free World for Indigenous Health Research, stating enous youth. This holistic theory [21–23] consists of
that this support is contrary to the health and well-being five determinants of behaviour intention (behavioural
agendas of Indigenous people [6]. Researchers and Indig- beliefs, normative beliefs, self-concept, emotions, self-
enous scholars are calling for more comprehensive and efficacy), and four determinants that impede/facilitate
responsive efforts to narrow the disproportionate tobacco the translation of intention to actual behaviour (knowl-
marketing and use among Indigenous youth, which is now edge, environment, salience, and habitual processing),
inclusive of e-cigarettes [3, 4, 7, 13]. and one recently added construct (split-second deci-
In Canada, youth vaping prevention efforts not only sion making [23] (see Fig. 1). This framework has been
remain sparse, but are also primarily designed to reach recently utilized to understand help-seeking among
the general population of Canadian youth, like the youth and young adults with mental health problems
national campaign, Consider the Consequences [14]. [24–27]. Given the comprehensive nature of the UTB,
Researchers have recently implored the tobacco control use of this theory in the context of Indigenous culture
community to stop rolling out generic tobacco control and historical colonialism will enable a deep under-
efforts in light of substantial evidence that tobacco use standing of the most salient determinants that under-
is underpinned by differential inequities experienced pin Indigenous youth decision-making around vaping,
by different populations, including Indigenous popula- ultimately informing the subsequent creation of more
tions [15]. In fact, studies have revealed robust corre- meaningful interventions that leverage factors promot-
lations between affiliation and engagement with their ing abstinence from vaping and address factors that lend
culture and Indigenous youth well-being [16–19]. In to vaping behaviour. The purpose of this study therefore,
this regard, it is recommended that Indigenous-based was to explore determinants that influence the decision
research is led by Indigenous people and includes to vape among Indigenous youth.

Fig. 1 Conceptual Framework of Findings
Methods questionnaire that asked about their demographic infor-

Overview mation (e.g., age, gender), social context (e.g., number
This qualitative study employed Indigenous research of older peers), tobacco product use and exposure, and
methods (e.g., traditional methods of data collection, social media use. For the interviews, seven youth were
like sharing circles) [28] to understand decision-making recruited via social media ads posted by a third party
around vaping among Indigenous youth. Indigenous consulting group (PH1 Research), as well as on the West-
research methods are described as methods that fully bank First Nation social media pages. All youth were
engage participants and incorporate experiential knowl- directed to contact a Syilx peer researcher. Youth were
edge which align with qualitative research [28]. The eligible if they identified as Indigenous, were between
methods of data collection must also be respectful of and the ages of 10 and 30 (in keeping with the Syilx defini-
include Indigenous protocols, values, and beliefs that are tion of “youth”), and able to communicate in English. All
important to the specific community [29]. In this regard, eligible youth gave informed consent, and youth assent
the research protocols herein were co-developed and and parental consent in the case of those under the age
implemented by two trained Syilx peer researchers (SW of 16. Youth then filled out a brief demographic ques-
and AS). In addition, all of the qualitative questions and tionnaire, and participated in a ~ 45 min interview with
questionnaire items asked of the participants were co- a peer researcher where they answered questions about
developed with the Indigenous peer researchers. This factors in relation to the UTB that influence their deci-
study also received a letter of support and approval by sion-making around vaping (see Table 1), as well as how
the Westbank First Nation Chief in addition to receiv- their culture underpins their decision-making (e.g., “How
ing Behavior Research Ethics Review Board approval do you see vaping in relation to Indigenous culture?”).
(#H20–02312). Each participant received a $25 gift card to thank them
for their time.
Data collection The Syilx peer researchers led the conceptualization,
Two types of data collection were employed in this study: planning, and organization of the sharing circle. Nine
semi-structured interviews, and an Indigenous shar- youth who had not previously participated in an inter-
ing circle [30]. All participants filled out a demographic view were recruited through an Indigenous-led summer

Table 1 UTB interview questions framework was reviewed and approved by the Syilx peer
UTB construct Example questions
researchers.
Behavioral beliefs Why do youth vape? Results

Normative beliefs Who in your life approves/disapproves of vaping? Sample
Self-concept How would you describe your peers who vape/don’t A total 16 youth who identified as Syilx First Nation
vape?
youth participated in this study. Youth ranged in age from
Emotions What feelings emerge when you think about vaping?
11 to 26, with the average age being 15.8. Most (62.5%)
Self-efficacy What strategies do you use to manage social pres‑
sures/stressful life events? (10/16) of the sample was male. All participants were
Split-second In what situations are you tempted/most likely to born in Canada. With the exception of one youth who
vape? had recently graduated high-school, the participants were
Knowledge What knowledge do you have about vaping? all currently attending school, which ranged from grade 6
Environment What makes it easy/difficult to vape? through to University. In relation to their social context,
Behavioral cues What might be some triggers to vaping? the majority of the sample lived in British Columbia and
Habits What habits might be associated with vaping? resided with 4 to 5 other individuals (68.75%;11/16 and
62.5%; 10/16 respectively). Most (81.25%) (13/16) of them
had older peers. In relation to their tobacco-product use
and exposure, many (56.25%) (9/16) youth had tried
camp program to participate in the sharing circle. All
smoking and vaping, and most of them had friends who
eligible youth gave informed consent, and parental con-
smoked (68.75%) (11/16) and vaped (87.5%) (14/16). Five
sent in the case of those under the age of 16. Youth then
(31.25%) youth reported living with someone who vaped,
filled out a brief demographic questionnaire, and partici-
50% (8/16) of youth reported that someone had tried to
pated in a 60 min sharing circle session that opened with
sell them vape juice, and 62.5% (10/16) of youth reported
traditional smudging by an Indigenous peer researcher
living close to a vape retail outlet.
from the community, and then engaged in traditional
We also examined social media use among youth.
methods of sharing. During the sharing circle, each par-
Most of the youth used Instagram (87.5%; 14/16), Snap-
ticipant passed around a ceremonial item (held by the
chat (87.5%;14/16), YouTube (100%; 16/16) and Tik Tok
person who is speaking) and expanded on the interview
(81.25%; 13/16) sometimes or all the time. Facebook
data, including their views on vaping among Indigenous
(50%; 8/16) and Messenger (56.25%; 9/16) followed
youth, views on school policy, and ideas for prevention
in popularity. Many youth reported seeing e-cigarette
messaging. They then engaged in a brainstorming activ-
advertisements sometimes or all the time on Instagram
ity around prevention strategies. The session concluded
(56.25%; 9/16), Snapchat (43.75%; 7/16), YouTube (37.5%;
with serving traditional food from their local community.
6/16) and Tik Tok (43.75%/16).
Each participant received a $30 gift card and a small gift
to thank them for their time.
Qualitative findings
The findings were grouped under three major categories,
and include: context of vaping among Indigenous youth,
Data analysis
UTB determinants to vaping decision-making, and sug-
The interviews and the sharing circle were digitally
gestions for prevention messages. Each of these catego-
recorded, transcribed by the research team, and then
ries have embedded themes with exemplary quotes. Each
integrated into NVivo 1.3 (QSR International) qualitative
major finding is associated with the number of partici-
data management software program for direct and con-
pants endorsing that finding to indicate saturation. Given
ventional qualitative content analysis [31]. The first stage
shared perceptions between both those who vaped and
of analysis included collaborative coding of two inter-
those who did not vape, their data was pooled together.
view transcripts among the first three authors (LS, SW,
See Fig. 1 for a conceptual framework that presents how
and AS) to develop the initial high-level codebook. The
each of these findings relate to one another, and to the
two peer researchers (SW and AS) then independently
UTB framework.
coded the remaining transcripts, noting nuances within
the codes and consulting with the lead author as needed.
Once complete, the lead author then reviewed the final Context of vaping among indigenous youth
coded set and worked with (SBD), an experienced scien- Disproportionate impact of the tobacco industry (n = 9)
tist in using the UTB framework [24], to apply the data First Nation youth agreed that vaping, although linked
to the UTB framework constructs. The final conceptual to tobacco, did not hold any spiritual value. They
explained that vaping is too modern and does not have

that historical and traditional connection in the same which they described as very important to their Indig-
way as tobacco. Conversely, youth described e-cigarettes enous culture. According to youth, vaping conflicted with
as another product that further emphasizes how Indig- these values. For example, several youth described the
enous youth are disproportionately impacted by the importance of being a role model in the community, and
tobacco industry. They explained that First Nation youth, they perceived vaping as something that would detract
especially those on reserves, have limited access to vap- from that.
ing both physically and financially. They cautioned that
Community, I’m thinking…of Indigenous communi-
this lends to the purchase of non-reputable and cheaper
ties so, making sure that people are sticking to like
products, ultimately lending to the use of more harmful
their ways and values… (Interview, 1012).
vaping devices by First Nation youth.
Not to be stereotypical. But I mean, like most indige- [I want to be] like this good role model so that they’re
nous youth, their family is poor. So I mean, like, they like, “Oh I want to be like her she doesn’t vape, she
don’t exactly have the money to buy the vape them- participates in culture, and she does her best to con-
selves. So they’ll have to buy some off brand, that’s nect with her community.” That’s the kind of person
cheaper (Sharing Circle). I want to be. I don’t want to be that kind of person
where it’s like, “Oh she vapes, oh she might get into
drinking.” (Interview 1003)
Vaping as colonialism (n = 12)
Youth also described vaping as being directly opposed to
traditional ceremony, and as something that is in conflict UTB determinants to vaping decision‑making
with their cultural values. They explained how important Themes related to UTB determinants to vaping decision-
it is to feel connected to their community, family, and making among Indigenous youth are detailed in Tables 2
culture, and the value of role-modeling within their band and 3. Table 2 provides a list of individual determinants
and community. Connection and role-modeling came up that influence intentions to vape and determinants that
frequently during the interviews and the sharing circle, translate intentions to vape to decision to vape. Table 3
Table 2 UTB determinants to vaping

Theme (UTB construct) Exemplary Quotes Saturation
(n = 16)
Individual determinants that influence intentions to vape

Vaping helps you cope (behavioral belief ) It all came to this point where its like “Wow, this is really cool” and “I see this 14
as something to get my mind off stuff.” (Interview, 1011)
I think they choose to vape to calm down maybe and to relieve stress and
anxiety because of things going on in the home, bad things. (Interview,
1002)
Vaping makes you cool (behavioral belief ) It could also be like “oh their doing it, and their cool” so its like uh, peer pres‑ 15
sure kind of thing. And they feel pressured like “oh if I don’t do this, then I’m
not cool.” And that’s something I’ve noticed a lot through out high school is
like the cool factor (Interview, 1003)
Network approval through vaping (normative belief ) I don’t think anyone really does [approve]. No one like advocates for it or 13
anything…its not like their like, “Yeah, do vape!”. They’re kind of like “Yeah, it’s
kinda bad for me, but I do it.” (Interview, 1001)
I would say my friends approve of it because I also know that they do that
[vape]. (Interview, 1012)
Social panic (split-second decision making) I think with most people it’s just social panic, like, kind of freeze in the 10
moment….you think you’ll be prepared for it when somebody offers you [a
vape], but then it really makes you freeze. And you don’t really…think about
it to an extent….you just [vape] in the moment. (Sharing Circle)
Determinants that facilitate the translation of intentions to vape to decision to vape
Lack of school policy enforcement (environment) It’s just not enforced….Its just like, like a vague threat that doesn’t really 12
actually [happen]. It’s like “This could happen to you” but it doesn’t. (Inter‑
view, 1001)
Access to vaping (environment) [It’s easy to vape] if my friends have it and their like, “Hey I got this off of 5
somebody” or something like that. (Interview, 1008)
I think more accessible cause there’s not like a smell really and yea it’s easier
to hide. So I feel like it’s the go to substance abuse. (Interview, 1012)

Table 3 UTB determinants to not vaping

Theme (UTB Construct) Exemplary Quotes Saturation
(n = 16)
Individual determinants that influence intentions to not vape

Vaping is bad for your lungs (behavioral belief ) Not many my peers attending gym class anymore because they 14
become short breath. Because they kept using their devices- cough‑
ing, some of them getting sick, because they took too much nicotine.
(Sharing Circle)
Vaping is like “digging yourself into a hole” (behavioral belief ) I was just getting more and more addicted to it and I was becoming sad, 10
gaining depression. And I had to dig myself out of that hole with friends
and family and having conversations about how I wasn’t feeling okay. I
had to go outside of my comfort zone and talk about how I was weak
when it came to addiction. (Sharing Circle)
Family/community connectedness (normative beliefs) It brings me hope and it makes me happy because participating in cul‑ 13
ture and connecting with my community means a lot to me. And I feel
like I learned more of not only the Nation I’m from, but also more about
who I am as a person. Cause like I feel like culture plays a huge role in
finding out who you are as a person and what you can do not only to
connect with your community, but also other communities within your
Nation. That’s how I think of it. (Interview, 1003)
Family values and beliefs (normative beliefs) When someone offers me something like that, I tend to think about 5
what my parents have told me…I tend to think about what my mother
tells me and what my dad tells me of what happens with that kind of
stuff. (Interview, 1011)
Engaging in culture (self-efficacy) Another thing I’d pick up is my runners for the unity run and like going 12
hiking. I’d rather go hiking around, running, dancing, and I’d be like,
“No, I’m good, I’m an athlete, and I’ve got to keep my health in mind.”
Because I’d rather participate in my culture and my community. (Inter‑
view, 1003)
Self-reflection (self-efficacy) What I did to stop was [by] questioning myself and saying, “Why am I 11
doing this? What am I gaining? Am I gaining anything?” “No”, was the
answer. I was getting nothing. (Sharing Circle)
Avoidance/resistance strategies (self-efficacy) I always try to get my friends to maybe draw, just talk, or find games that 10
we can do together… because I mean, it was really a red flag whenever
they asked to go outside, because I mean, that’s where they mostly did
[the vaping.] (Sharing Circle)
Determinants that facilitate the translation of intentions to not vape to decision to not vape
Access to supportive adults/band (environment) And I had, I had to find a way out [of vaping] and my way out was by 12
[having conversations] with people I can trust. That was my way to stop
vaping before. (Sharing Circle)
School policies (environment) I think a school is supposed to be like a good role model. I guess not [a 5
place] to do bad things. (Interview, 1008)
[School policies] encourage many people not to bring any vapes, and
encourage people to do more learning than vaping. Schools shouldn’t
be the place where you have habits like that. (Interview, 1002)
provides a list of individual determinants that influence All I can say is that the methods that we have now for
intentions to not vape and determinants that translate prevention of youth using vapes, drugs, this and that
intentions to vape to decision to vape. are just not really working. If I’m gonna be honest, at
least in my general area, because I see people do it
more and more and more because they get more and
Suggestions for prevention messages more annoyed at the fact that their things are getting
Need to resonate with why indigenous youth vape (n = 12) taken, and they get more stressed, and have anxiety,
Youth agreed that current prevention strategies were not and then they go back to it, and then they get into that
resonating with youth. They said that prevention efforts loop of, “I need something to help me with this prob-
are not acknowledging what is driving the behavior in lem”…that’s their only way of coping. (Sharing Circle)
the first place. One youth mentioned that many youth are
vaping to help them cope. In this case, confiscating vapes The youth emphasized the need for prevention efforts
is not helping them: that resonate with youth, not only such that they address

the underlying factors that lend to vaping uptake, but also and demonstrates its potential for use in other commu-
leverage the strengths and resiliency of Indigenous youth nity contexts and with other demographics, enhancing
to affirm intentions to stay away from vaping. the ability to develop and tailor behavior change inter-
ventions that are theoretical and evidence-based.
One of the key findings of this study is the link
Need to be where youth are at (n = 12)
between vaping and the effects of colonialism. That
Youth explained that message content and delivery chan-
youth were turning towards vaping as a result of inter-
nels need to meet youth where they are at. They said that
generational trauma and negative impacts of colonial-
prevention needs to be a focus within their community,
ism points towards an important history that underpins
as well as on social media channels that they frequently
health risk behaviors among Indigenous youth, like vap-
use (e.g., Instagram). Messages that would resonate with
ing. While coping, curiosity, and peer influences played
them should include a focus on helping youth self-reflect
a role in their uptake, similar to their non-Indigenous
(e.g., asking yourself “why?”, “what’s the point?”, “what
peers [1], the findings reinforce the need to pay atten-
do you gain”, “how does this impact your culture?”, “how
tion to another layer, a history that underpins these
does this impact your role modelling?”), describing things
determinants of vaping. These findings build on previous
that they could buy instead of vaping, helping them build
research that describes how the erosion of social struc-
skills to manage situations of social panic, have peers
tures and intergenerational connectedness as a result of
share their personal experiences with vaping, and have
colonialism have directly and indirectly impacted the use
endorsement by celebrities/influencers.
of commercial tobacco products [7, 32–34]. The tobacco
industry has capitalized on this erosion to promote their
Discussion products, and are now targeting Indigenous people with
This analysis aimed to identify factors that influence the alternative nicotine delivery systems (including e-ciga-
decision to vape among Indigenous youth. While Indig- rettes) as a way to make amends for past harms caused
enous scholars have called for Indigenous-specific evi- by cigarette marketing, essentially as a form of reconcilia-
dence around youth tobacco use behaviors given their tion [4, 6, 7]. Because Indigenous youth are more likely to
unique history and experiences [3, 4, 6](Seo & Chang be exposed to risk factors associated with substance use
2021; Waa et al., 2019; Waa et al.., 2020; Thompson et al., [35], which puts them at higher risk for using e-cigarettes
2020; Thompson & Thompson, 2020)), we have yet to [7], allowing marketing of these products to Indigenous
understand the interplay between Indigenous youth people opposes truth and reconciliation efforts. Even
contexts and salient behavioral constructs surround- more so, by not investing resources and engaging Indig-
ing the decision to vape. We explored this by grounding enous people to specifically protect Indigenous youth
a novel behavior change theory, the UTB, in a culturally may also be viewed as complacent colonization. Having a
responsive approach, and using Indigenous-led research clear plan of investment, implementation, and evaluation
methods. of efforts to protect Indigenous youth from the harms of
The UTB surfaced as a flexible model that can be inte- the tobacco industry is a necessary step towards truth
grated with frameworks and contexts that are true to the and reconciliation [13].
communities in which they are situated. In this study, Drawing on their cultural strengths (e.g., wisdom from
we found that a history of colonialism and being dispro- elders, support from their community/band, engag-
portionately impacted by the tobacco industry played a ing in cultural activities, viewing themselves as a role
key role in what behavior change constructs surfaced as model in their community) were important to helping
important factors in driving the decision to vape among Indigenous youth think through their decision-making
Indigenous youth, and how Indigenous youth need to around vaping. Researchers have found that connection
be supported. For example, we found that the behavio- with their cultural values and traditions is an important
ral belief that vaping helped youth cope with stressors, way to combat the effects of colonialism, allowing Indig-
such as a home environment that entailed violence or enous people to heal [16, 18, 19]. Our findings extend this
substance use, as a result of colonialism, was a key driver research by revealing that culture, community connect-
in uptake among Indigenous youth. Conversely, con- edness, and traditional ceremony and values are impor-
nectedness with their community and their culture (the tant to Indigenous youth of today, and are essential to
opposite of colonialism) (normative beliefs), was key to protecting them from engaging in health risk behaviors,
prevention of vaping uptake, and further supported other and specifically vaping. In this regard, prevention mes-
protective constructs (e.g., self-efficacy) in relation to saging needs to reflect these values, which can only truly
vaping. Being able to ground the UTB constructs within be done by continuing to engage Indigenous youth in the
the participant contexts is a major strength of this model planning and development of prevention messages to

ensure that they resonate with their contexts and value urban Indigenous youth, and the perspectives and expe-
systems [18]. riences of youth living on reserves may differ. Further,
The findings provide some very tangible directions for recruitment procedures may have resulted in voices
developing prevention messaging that resonates with being excluded. For example, by recruiting youth partici-
the contexts of Indigenous youth. A number of determi- pating in an Indigenous summer camp program, the find-
nants point to what types of content should be included ings reflect the views of youth who are already engaging
in these messages. For example, messages that leverage with their culture and see this as an important aspect of
the cultural strengths of Indigenous youth (e.g., impor- their identity. Finally, due to the nature of the sharing cir-
tance of being a role model), promote self-efficacy (e.g., cle, there may have been alternative views not voiced in
suggest strategies and refusal skill building to deal with the presence of peers. However, this Indigenous method
situations that might result in the split-second deci- of data collection is also a major strength of the study
sion to vape), and reinforce their community supports because it is a method that is familiar to the youth, and
(e.g., elders) hold significant promise in resonating with is grounded in communication traditions that are impor-
Indigenous youth. The unanimous agreement among the tant to their culture. Another major strength of this study
youth participants that social media would be the most is that it employed a culturally responsive approach, and
desirable mode of delivery for these messages builds on a comprehensive behavior change theory to understand
previous research findings that this is the most effective factors that influence vaping decision-making among
way to reach today’s youth [36]. However, in light of the Indigenous youth. This provides future researchers with a
findings, a critical aspect in future development of pre- strong theoretically-informed evidence base from which
vention messages is the engagement of Indigenous youth to address the issue of vaping among Indigenous youth.
throughout all aspects of research.
The findings also hold policy implications. In particu-
lar, the accessibility of vaping products among the par- Conclusions
ticipants was noteworthy. Not only did the majority of The results of this study identify the most pertinent
youth describe proximity to a vape store, in addition to factors that underpin decision-making around vaping
access through peers or older individuals in their lives among Indigenous youth. Through the use of the UTB
(e.g., older friends, parents, etc.), but they also described and a culturally-responsive approach, the findings pro-
a lack of regulations (vaping indoors) and policy enforce- vide a strong contextual and theoretical base for under-
ment (school policies) as enabling easy access to vaping. standing these factors and providing a way forward. To
What these findings indicate is that more attention needs effectively address vaping among Indigenous youth,
to be paid to policy implementation at government, com- continued engagement of Indigenous youth in planning,
munity, and school levels. On a government level, policy developing, implementing, and evaluating both preven-
efforts are needed to more effectively reduce youth expo- tion and policies efforts are a necessity.
sure to vape advertisements and retail. Policies around Acknowledgements
retail locations are also needed. For example, proximity The authors would like to thank the youth who participated in this study.
to schools, recreation centers, and Indigenous communi- Authors’ contributions
ties should be considered. On a community level, regu- LS conceptualized the study. All authors developed a plan for conducting
lations on the places where vaping is permitted need to the study. SW and AS conducted data collection. All authors analyzed and
interpreted the data. LS drafted the paper for publication. All authors read and
be examined. It is important that a community enforces approved the final manuscript.
regulations that strengthen the self-determination and
decision-making agency among Indigenous youth, such Funding
This research did not receive any specific grant from funding agencies in the
as through limiting or banning public indoor use. On a public, commercial, or not-for-profit sectors.
school level, the findings indicate a clear need to enforce
vaping policies. Availability of data and materials
The datasets generated and analyzed during the current study are not pub‑
licly available due to personally identifiable data from the participants.
Limitations and strengths
There are some limitations and strengths that must be Declarations
noted in this study. First, the findings represent the voices
Ethics approval and consent to participate
of Syilx First Nation youth, and may not be transfer- This study also received a letter of support and approval by the Westbank First
rable to other Nations. It is also a strength of this study Nation Chief in addition to receiving Behavior Research Ethics Review Board
because the findings represent a united voice, and other approval (#H20–02312). All methods were performed in accordance with the
relevant guidelines and regulations. All participants provided written informed
Nations can compare how their values and beliefs might consent.
align. In addition, the findings represent the voices of

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RESEARCH Open Access

Factors that influence the decision to vape

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Fig. 1 Conceptual Framework of Findings

Methods questionnaire that asked about their demographic infor-

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Behavioral beliefs Why do youth vape? Results

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Table 2 UTB determinants to vaping

Individual determinants that influence intentions to vape

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Table 3 UTB determinants to not vaping

Individual determinants that influence intentions to not vape

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