This study explored perceptions of marijuana use and abstinence among urban and rural Appalachian high school students using photovoice, enabling this subset of youth to co-construct their perceptions of marijuana use and abstinence. Twelve adolescents, ages 14-17, participated in the study. Participants identified managing stress and feeling peer pressure as two reasons teens might use marijuana. Participants identified four reasons for adolescent marijuana abstinence including having positive relationships, identifying with religion/spirituality, participating in extracurricular activities, and avoiding negative outcomes. Findings suggest that participants may smoke marijuana due to peer pressure and to cope with stress. Collective approaches including families, communities, and faith organizations may be important marijuana use prevention approaches for Appalachian adolescents.