Appalachian Kentucky reports some of the highest rates of respiratory illness in the United States, including chronic obstructive pulmonary disease and asthma. While smoking rates are high in the region, unexplained variation remains, and community-engaged research approaches are warranted to identify contributing factors. The Mountain Air Project’s community advisory board recommended that investigators invite youth to provide their perspectives on possible contributing factors to respiratory illness, and we undertook an exploratory study to determine the utility of photovoice to elicit such perspectives with this population. While photovoice has been employed for other youth-focused health studies in Appalachia, to our knowledge, this work represents the region’s first environmental study using photovoice among youth. Over eight weeks, ten participants (age 12–18) represented their perspectives through photographs and accompanying narratives. A brief thematic content analysis of the youth narratives that accompanied the photos revealed three primary themes of environmental determinants of respiratory illness. These themes included compromises community members make regarding respiratory health in order to secure a livelihood; tension between cultural legacies and respiratory health; and consequences of geographic forces. This study demonstrates the value of incorporating youth perspectives in environmental health research, and that photovoice was a valuable approach to elicit such perspectives.