These findings extend prior research on the timing of the onset of tobacco use by using longitudinal analyses from three contemporary cohort studies to include not just cigarettes, but also e-cigarettes, cigar products, and hookah. Among those who were never-users of tobacco products, young adults began to ever and currently use all tobacco products more than youth in these samples, a marked departure from prior decades of research.

Variation in diabetes screening in clinical practice is poorly described. We examined the interplay of patient, provider, and clinic factors explaining variation in diabetes screening within an integrated health care system in the U.S. RESEARCH DESIGN AND METHODSWe conducted a retrospective cohort study of primary care patients aged 18-64 years with two or more outpatient visits between 2010 and 2015 and no diagnosis of diabetes according to electronic health record (EHR) data. Hierarchical three-level models were used to evaluate multilevel variation in screening at the patient, provider, and clinic levels across 12 clinics. Diabetes screening was defined by a resulted gold standard screening test. RESULTSOf 56,818 patients, 70% completed diabetes screening with a nearly twofold variation across clinics (51-92%; P < 0.001). Of those meeting American Diabetes Association (ADA) (69%) and U.S. Preventive Services Task Force (USPSTF) (36%) screening criteria, three-quarters were screened with a nearly twofold variation across clinics (ADA 53-92%; USPSTF 49-93%). The yield of ADA and USPSTF screening was similar for diabetes (11% vs. 9%) and prediabetes (38% vs. 36%). Nearly 70% of patients not eligible for guideline-based screening were also tested. The USPSTF guideline missed more cases of diabetes (6% vs. 3%) and prediabetes (26% vs. 19%) than the ADA guideline. After adjustment for patient, provider, and clinic factors and accounting for clustering, twofold variation in screening by provider and clinic remained (median odds ratio 1.97; intraclass correlation 0.13). CONCLUSIONS Screening practices vary widely and are only partially explained by patient, provider, and clinic factors available in the EHR. Clinical decision support and system-level interventions are needed to optimize screening practices. Diabetes screening identifies individuals with undiagnosed, asymptomatic type 2 diabetes or prediabetes who are eligible for evidence-based interventions to prevent or delay type 2 diabetes and its complications. National screening guidelines, such as the American Diabetes Association (ADA) (1) and U.S. Preventive Services Task Force (USPSTF) (2), help clinicians identify individuals at increased risk for type 2 diabetes and target screening tests in clinical practice. Despite screening recommendations, .7 million U.S. adults with type 2 diabetes and 74 million U.S. adults with prediabetes remain undiagnosed (3). Nationally representative data indicate significant gaps

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