Study design, setting, and methodological orientation

This qualitative study was conducted at a university in Fujian Province, China, during October 2025. The university is located in a region with historical significance for overseas Chinese emigration to Southeast Asia and hosts a substantial population of Chinese Indonesian students. The timing was approximately three years after China implemented e-cigarette flavor restrictions (October 2022), providing relevant regulatory context.

The study employed Interpretive Phenomenological Analysis (IPA), an approach that examines how individuals make sense of significant life experiences¹⁶. IPA is grounded in phenomenology, hermeneutics, and idiography, and is appropriate for small, homogeneous samples where depth of analysis takes precedence over breadth¹⁷. The acculturation framework of Berry⁷ served as a sensitizing theoretical lens, guiding attention to cultural adaptation processes while maintaining openness to participants’ own meaning-making.

This study adhered to the Standards for Reporting Qualitative Research (SRQR) guidelines¹⁸. The complete SRQR checklist is provided in the Supplementary file.

Ethical considerations

This study received ethical approval from the Research Ethics Committee of Fujian Polytechnic Normal University (Approval No. 2025-02). All participants provided written informed consent before participation, including consent to audio recording and the publication of anonymized data. Given the sensitive nature of tobacco use data, particularly for female participants from cultures where female smoking is stigmatized, additional confidentiality protections were implemented. Participants were assured their information would not be shared with university administrators or family members. All identifying information has been removed; participants are identified as Participant 1 (P1), Participant 2 (P2), and Participant 3 (P3) throughout.

Research team and reflexivity

The primary researcher is a Chinese female academic with experience in health communication research. She conducted all interviews and analysis. The researcher has no personal history of tobacco or e-cigarette use and approached participants’ accounts with openness and curiosity rather than judgment. Before interviews, the researcher disclosed her academic role and research purposes to participants. No prior relationship existed between the researcher and participants. Throughout the analysis, the researcher maintained reflexive awareness of her position as a non-smoker and as someone from a different cultural background than the participants, using a reflexive journal to document analytical decisions and interpretive choices.

Sampling strategy

Participants were recruited from a larger survey examining health and cultural adaptation among heritage students at the university (n=45; Chan 2025, unpublished institutional survey). Purposive sampling identified individuals meeting the inclusion criteria: 1) Indonesian nationality with Chinese ancestry; 2) female gender; 3) current e-cigarette use (defined as any e-cigarette use in the past 30 days); and 4) willingness to participate in in-depth interviews. Three participants met all criteria and consented to participate.

The sample size of three is consistent with IPA methodology recommendations. Smith et al.¹⁶ state that IPA studies typically include 3–6 participants, emphasizing depth over breadth. Malterud et al.¹⁹ information power concept supports smaller samples when specificity, clarity of the theoretical framework, dialogue quality, and analytical depth are strong – all characteristics present in this study, given the highly specific population and the substantial interview depth achieved.

Data collection methods

Before interviews, participants completed a comprehensive questionnaire. Questionnaire data served exclusively as individual-level contextual profiles to enrich the interpretive analysis of each participant’s interview account; they are not used for statistical inference or generalization. The questionnaire assessed the following: demographics and cultural identity (age, year of study, generation of Chinese descent, ancestral province, religion, and home language, defined as the primary language used at home in Indonesia); acculturation difficulties (20 items covering climate, food, social relationships, language, academic adjustment, and cultural understanding, rated on a 5-point scale from 1=no difficulty to 5=very difficult); social support (13-item scale adapted from the Multidimensional Scale of Perceived Social Support, rated 1=strongly disagree to 5=strongly agree); psychological wellbeing (Center for Epidemiologic Studies Depression Scale, 10-item version [CES-D-10]²⁰, rated 1=rarely to 4=most of the time); health behaviors (sleep duration categorized as <7, 7–8, or >8 hours; exercise frequency categorized as rarely/never, a few times per month, 1–2 times per week, 3–5 times per week, or daily; and tobacco use type and frequency); stressors experienced in the past month (checklist); help-seeking preferences; and mental health service awareness.

Semi-structured interviews were conducted 26–31 October 2025, in private meeting rooms at the university campus. Two participants (P1, P2) were interviewed twice to achieve greater depth; one participant (P3) completed a single extended interview with bilingual interpretation assistance due to limited Chinese proficiency. Interviews lasted 20 to 40 minutes per session. Total transcribed text: approximately 49000 characters.

The interview guide addressed: background and pathway to China; cultural adaptation experiences; academic adjustment and stressors; e-cigarette use history and current practices; use contexts and environments (dormitory, campus, public spaces); perceptions of social norms regarding female smoking/vaping in Indonesia versus China; family awareness and reactions; peer relationships; and health awareness. The interviewer probed specifically on use contexts (e.g. situations that prompted use), affective states before and after use, and the relationship between experienced stressors and use patterns.

Interviews were conducted primarily in Mandarin Chinese with code-switching to Indonesian and English as needed. All interviews were audio-recorded and transcribed verbatim by the researcher. Transcripts were reviewed against audio recordings for accuracy.

Data analysis

Analysis followed the IPA procedures outlined by Smith et al.¹⁶. The process began with reading and re-reading each transcript multiple times alongside questionnaire data to achieve immersion and develop an overall sense of each participant’s account. Initial noting involved making detailed exploratory comments throughout each transcript, including descriptive comments (summarizing content), linguistic comments (noting specific language use, metaphors, and tone), and conceptual comments (engaging with interpretation and meaning at a more abstract level). Emergent themes were then developed by analyzing exploratory comments to identify themes capturing the psychological essence of passages, expressed as concise phrases reflecting both participant content and researcher interpretation. These emergent themes were examined for patterns and connections, resulting in clustering into main themes and subthemes through processes of abstraction, subsumption, and polarization. Steps were repeated for each participant with deliberate bracketing of themes from previous cases to allow new themes to emerge. Finally, cross-case analysis examined themes from all three cases for convergence and divergence, resulting in a final thematic structure representing shared and distinctive aspects of participants’ experiences.

No qualitative software was used; analysis was conducted manually using printed transcripts and handwritten annotations. Trustworthiness was enhanced through maintaining a reflexive journal documenting analytical decisions, preserving idiographic detail through presentation of individual participant characteristics, providing verbatim quotations to ground interpretations in participant voices, integrating questionnaire data to contextualize interview findings, and transparent reporting following SRQR guidelines.

Participant profiles

All three participants were female Chinese Indonesian college students aged 18–21 years, with intermediate Chinese proficiency (Hanyu Shuiping Kaoshi [HSK] 3–4). Each participant’s profile is summarized briefly below to provide idiographic context for the thematic analysis that follows (Table 1).

P1 (aged 18 years, second-year student, Catholic, ≥5th generation Chinese descent, Fujian ancestral province) reported the greatest adaptation difficulties across multiple domains. She rated overall cultural adaptation as quite difficult (4/5), with academic teaching methods and academic pressure both at maximum difficulty (5/5). P1 was a dual user who primarily smoked conventional cigarettes but continued to use e-cigarettes occasionally. She had initially used e-cigarettes in Indonesia before transitioning primarily to conventional cigarettes after arriving in China, citing taste preferences. Her e-cigarette use frequency remained unchanged since arriving in China. P1 reported the broadest range of stressors (language, academic, financial, loneliness, and career concerns), rarely exercised, and slept less than seven hours per night.

P2 (aged 20 years, third-year student, Buddhist, 3rd generation, Guangdong ancestral province) reported minimal overall adaptation difficulty (1/5) despite finding academic teaching methods quite difficult (4/5). P2 was a current daily e-cigarette user who reported increased use since arriving in China. She used e-cigarettes exclusively and did not smoke conventional cigarettes. Notably, P2 reported being very dissatisfied with social support overall (score 1/5) and feeling hopeful about the future only rarely (score 1 on the CES-D-10 item). She indicated she would not seek help for psychological distress.

P3 (aged 21 years, second-year student, Christian, 3rd generation, unknown ancestral province) reported moderate difficulty across acculturation domains (3/5). P3 was a current daily e-cigarette user who also used conventional cigarettes periodically (dual user). She reported increased e-cigarette use since arriving in China and sourced e-cigarettes from Indonesia. P3 was the only participant who indicated willingness to see a professional therapist for psychological distress.

All three participants reported sleeping less than seven hours per night and feeling lonely often (score 3 on the CES-D-10 loneliness item). All were aware of university mental health services but had never used them.

Thematic structure

Analysis yielded four main themes with their corresponding subthemes, presented in Table 2.

Theme 1: Social initiation and peer-embedded use

Peer influence as an entry point

All three participants traced their e-cigarette initiation to peer influence during Indonesian high school:

confirming this occurred in high school. P2 similarly explained:

P3 described mixed-gender peer influence:

When asked about initial use contexts, P2 clarified that she used it primarily with friends rather than alone during that period:

Notably, when asked about the gender composition of influential peers, P1 clarified that female classmates were the primary influence, while P3 described a mixed-gender peer context. This pattern of peer-mediated initiation occurred within Indonesia’s largely unregulated e-cigarette market.

Continuation within co-national networks

After arriving in China, e-cigarette use continued primarily within Indonesian peer networks rather than expanding to include Chinese friends. P2 explained:

When asked about the composition of her social circle, P2 confirmed:

Limited integration with Chinese peers

Participants described limited social integration with Chinese students. P3 reported that her close friendships in China were with ‘Indonesian friends’, describing relationships with Chinese students as ‘not very close’. Questionnaire data corroborated this pattern: P1 rated ‘making friends with Chinese students’ as quite difficult (4/5), while P2 found it less challenging (2/5) but still maintained primarily co-national friendships for e-cigarette-related socializing.

Theme 2: Acculturation stressors without stress-coping use

Questionnaire and interview data revealed substantial acculturation challenges across all three participants. A notable pattern, however, was that participants explicitly described their e-cigarette use as unrelated to the acculturation stressors they reported.

Academic pressure and language barriers

Academic adjustment emerged as a major challenge. P1 reported the highest difficulty levels, rating both ‘adapting to teaching methods’ and ‘dealing with academic pressure’ at the maximum (5/5). P1 elaborated on language-related academic difficulties:

P2 similarly described academic challenges despite reporting lower overall adaptation difficulty:

All three participants reported language barriers among their stressors on the questionnaire, and two specifically identified academic pressure.

Loneliness and limited social support

All three participants reported feeling lonely often (score 3) on the CES-D-10 loneliness item. P2 additionally reported being very dissatisfied with social support overall (score 1/5) and disagreed that she had friends at school with whom to share joys and sorrows (score 2/5). Interview data illuminated the loneliness dimension. P1 commented with apparent resignation:

P3 described a temporal pattern of adaptation:

Sleep insufficiency and health behavior patterns

All three participants reported sleeping less than seven hours per night. Exercise patterns varied substantially: P1 reported rarely or never exercising, P2 exercised a few times monthly, and P3 exercised one to two times weekly. When asked about stress management strategies, P1 described ‘sharing with friends’ and ‘going out … or sleeping’. None of the participants mentioned e-cigarette use as a coping or stress management strategy when asked about how they dealt with difficulties.

Explicit disconnection from stress-coping

Despite experiencing substantial stressors – academic pressure, language barriers, loneliness, sleep insufficiency, and (for P2) social support dissatisfaction – participants explicitly denied that e-cigarette use served stress-coping functions. When asked directly whether e-cigarettes helped with stress, P3 was unequivocal:

P1, despite reporting the most severe adaptation difficulties, similarly denied the stress-use connection. P2 framed her use as leisure rather than coping:

Participants’ accounts consistently positioned e-cigarette use within recreational and habitual frames rather than coping frames, though this self-characterization should be interpreted alongside the possibility that habituated use may serve implicit regulatory functions not captured by explicit self-report.

Theme 3: Navigating gendered social norms

Indonesia as a restrictive environment

Participants consistently described Indonesia as holding strong prohibitions against female tobacco use. P2 articulated this comprehensively:

When asked specifically about religious influences, P2 confirmed that Muslim women face particular constraints but extended the prohibition beyond religious boundaries:

P3 captured the gendered dimension:

China is relatively permissive

In contrast to Indonesia, participants perceived China as holding more tolerant attitudes toward female smoking. Participants’ perception of China as more permissive operated across several dimensions. Reduced public stigma:

Diminished family surveillance due to geographical distance expanded social spaces for evening outings: P2 noted increased nighttime socializing compared to Indonesia; and the absence of religious prohibition frameworks that reinforced gender-specific tobacco norms in Indonesia. This perceived permissiveness did not appear to directly increase participants’ e-cigarette use, but it may have influenced where and with whom they felt comfortable using.

Use environments: Outside dormitories

E-cigarette use occurred primarily outside dormitory spaces, channeled into external social contexts. P2 explained her typical use context:

P3 similarly indicated minimal dormitory use. P2 noted that coming to China had changed her nighttime social patterns:

Family concealment

All three participants engaged in some form of concealment regarding their tobacco/e-cigarette use with families, enabled by geographical distance and digital communication patterns. P2 stated directly:

P3 acknowledged that her parents knew about her past smoking:

P1 presented a similar pattern of mutual face-saving. These concealment practices are enabled by geographical distance – participants communicate with families primarily through digital platforms (WhatsApp, WeChat) that allow selective disclosure.

Theme 4: Habituated practice and flavor preferences Habit framing

Participants consistently framed e-cigarette use as a habituated practice rather than functional coping. P3 stated:

P2 similarly characterized use as leisure:

This habit framing persisted even when participants acknowledged awareness of health risks. None expressed strong quit intentions.

Cross-border product sourcing

Participants expressed clear preferences for fruit-flavored e-cigarettes, which are available in Indonesia but have been restricted in China since October 2022 ¹⁵. P2 liked fruit flavors, and explained her sourcing:

P3 described similar practices:

When asked whether she had tried Chinese e-cigarette products, P3 confirmed she had but rejected them:

Participants’ reported sourcing practices illustrate how mobile populations may navigate divergent regulatory environments.

Divergent behavioral trajectories

The three participants exhibited distinct behavioral trajectories after arriving in China. P2 reported increased e-cigarette use, attributing this to peer environment and lifestyle changes:

P3 similarly reported increased use alongside periodic conventional cigarette use, sourcing e-cigarettes from Indonesia and supplementing with local cigarettes. P1 presented a distinctive trajectory. She had primarily transitioned to conventional cigarettes after arriving in China, citing taste preferences:

She continued to use e-cigarettes occasionally. The inconvenience of sourcing Indonesian products may have contributed to her shift toward conventional cigarettes as her primary product. These divergent trajectories suggest that cross-cultural transition affects e-cigarette use differently depending on individual acculturation profiles, product access, and peer environments.

Acculturation stressors without stress-coping use

A central finding was the explicit disconnection participants drew between their substantial adaptation challenges and e-cigarette use. Questionnaire data documented significant stressor exposure: all participants frequently experienced loneliness, all reported insufficient sleep, multiple stressors were identified (academic, financial, language-related), and P2 reported very low satisfaction with social support. These patterns align with the comprehensive review of Smith and Khawaja³ identifying academic, sociocultural, and psychological challenges as common among international students, and the documentation of Li and Sun⁵ of sleep difficulties during acculturation.

Yet when asked directly about the relationship between stress and e-cigarette use, participants consistently denied causal connections. This finding diverges from the Kim et al.⁵ review documenting associations between acculturative stress and smoking among Asian populations. Our participants, instead, framed use as a habit, leisure, and social practice – described as functionally disconnected from their acknowledged difficulties.

Several interpretations warrant consideration, drawing on Schwartz et al.²¹ reconceptualization of acculturation as a multidimensional process. First, participants may genuinely experience use as a non-functional habit, having been initiated through social influence before migration and maintained through behavioral automaticity. Second, the timing of initiation – prior to migration, during Indonesian high school – means that e-cigarette use predated acculturation stressors entirely. Use patterns established before migration may persist through habit mechanisms without becoming linked to post-migration stressors²¹. Third, cultural scripts may shape how use is understood and articulated; framing e-cigarette use as casual leisure rather than problematic coping may reflect impression management or genuinely different meaning systems regarding nicotine use.

However, this finding should be interpreted with caution. Self-report may not fully capture implicit or automatic coping processes (e.g. affect regulation, boredom management, negative reinforcement) that are common in habituated substance use. The distinction between ‘habit’ and ‘implicit coping’ is analytically challenging, and future research using ecological momentary assessment or more intensive probing techniques may be better positioned to distinguish these processes.

Gendered social norms and the acculturation paradox

Participants perceived China as more tolerant of female smoking than Indonesia, consistent with the ‘acculturation paradox’ documented among Asian immigrant women in Western contexts^9,10. Chen et al.⁹ and An et al.¹⁰ found that higher acculturation among Asian American women was associated with increased smoking, attributed to relaxation of traditional gender prohibitions. Our findings extend this literature to a non-Western receiving context.

However, the mechanism may differ from traditional acculturation processes. Our participants were not adopting Chinese norms per se – their e-cigarette use predated arrival in China. Rather, the perceived permissiveness may have enabled maintenance of existing behaviors with reduced psychological conflict and channeled use into more visible public contexts. The Salant and Lauderdale⁸ critical review of acculturation measurement in Asian immigrant health research is relevant here, as they argue that acculturation is often measured inadequately, conflating exposure to host culture with adoption of host behaviors. Our participants were exposed to Chinese environments but maintained Indonesian peer networks and behavioral patterns. This aligns with the Schwartz et al.²¹ argument that acculturation involves bidimensional processes wherein heritage and receiving culture orientations operate independently. Heritage students studying in ancestral homelands may exhibit a distinct adaptation pattern that warrants nuanced theoretical treatment.

Peer networks and behavioral maintenance across borders

Consistent with the Firth et al.⁶ finding of increased e-cigarette use during study abroad, two of our three participants reported increased use after arriving in China. However, the mechanism differs from that proposed by Firth et al.⁶. Rather than adopting host country behaviors, our participants maintained use within co-national networks that reproduce home country behavioral norms. Kim et al.⁵ emphasized peer networks as critical influences on tobacco use among Asian populations; our findings suggest that these networks continue to operate transnationally among international students.

Strengths and limitations

The study strengths include a focus on an unexplored population at the intersection of multiple understudied dimensions; integration of questionnaire and interview data providing both contextual case profiles and qualitative depth; employment of IPA methodology appropriate for small-sample experiential research^16,17; and adherence to SRQR reporting guidelines¹⁸.

The study has limitations. As a qualitative, cross-sectional study, this research cannot establish causal relationships between acculturation factors and e-cigarette use patterns. The sample of three participants, while appropriate for IPA methodology^16,19 limits the generalizability of the findings. The fact that only three of 45 surveyed students met all inclusion criteria and consented to participate raises the possibility of selection bias; those who agreed to discuss a stigmatized behavior may differ systematically from those who declined. Language barriers affected data collection, particularly with P3. Self-report data may be subject to social desirability bias regarding a stigmatized behavior, and the interview protocol may not fully capture implicit coping processes that participants did not articulate as such. The sample represents students at one university in Fujian – experiences may differ in other locations or among male Chinese Indonesian students.

Future research

These findings point to several areas warranting further investigation. Larger, multi-site studies are needed to examine whether the patterns observed here – particularly the disconnection between acculturation stress and e-cigarette use among pre-migration users – extend to broader international student populations. Longitudinal designs that track e-cigarette use trajectories from pre-migration through post-migration adjustment would help disentangle temporal relationships between acculturative processes and use patterns. Research using ecological momentary assessment could better capture situational use contexts and implicit coping processes that cross-sectional interviews may not detect. Additionally, studies examining male international students and students from different sending countries would help determine the scope of the gendered dynamics observed here.