About

Steven M Smith is an Associate Professor and Chair of the Department of Pharmaceutical Outcomes and Policy at the University of Florida College of Pharmacy. He also holds a courtesy appointment in the Division of Cardiovascular Medicine within the College of Medicine and serves as Co-Director for the UF Center for Integrative Cardiovascular and Metabolic Diseases. Dr. Smith received his PharmD degree from the University of Florida College of Pharmacy, completed a PGY-1 residency at the North Florida/South Georgia Veterans Health System, and completed a postdoctoral fellowship in Family Medicine, during which he participated in the Advanced Postgraduate Program in Clinical Investigation and earned a Master of Public Health. His research focuses on cardiovascular pharmacotherapy, particularly hypertension and cardiometabolic disease, with an emphasis on resistant hypertension. His work employs observational methodologic approaches and data sources such as electronic health records, administrative claims, and clinical trial data. Dr. Smith's research is funded by the National Heart, Lung, and Blood Institute, PCORI, and the U.S. Department of Defense. He is an elected Fellow of the American Heart Association and the American College of Clinical Pharmacy, and a member of several professional organizations including the American College of Cardiology and the International Society for Pharmacoepidemiology. He has held leadership roles in national initiatives related to hypertension and cardiovascular health, and he co-coordinates a graduate course on Measurement in Pharmaceutical Outcomes Research. His contributions include advancing understanding of antihypertensive prescribing, resistant hypertension, and population-level cardiovascular outcomes.

Research topics

• Internal medicine
• Medicine
• Cardiology
• Surgery
• Intensive care medicine
• Emergency medicine
• Business
• Actuarial science

Selected publications

• Diagnostic Performance of Urinary Biomarker Tests in Detecting Bladder Cancer: A Systematic Review, Meta-analysis, and Network Meta-analysis

  Urology · 2026-02-04

  article
  PublisherDOI

• Association Between Different Analgesic Use and Hypertension Among Medicare Beneficiaries With Osteoarthritis

  Journal of the American Geriatrics Society · 2026-03-15

  articleSenior author

  BACKGROUND: In older adults with osteoarthritis (OA) and hypertension (HTN), analgesic use may elevate blood pressure and cardiovascular risk. Whether comorbid HTN influences initial analgesic choice remains unclear; we examined initial analgesic use in Medicare beneficiaries with incident OA, comparing those with and without HTN. METHODS: We conducted a retrospective cohort study using 2011-2022 nationally representative Medicare beneficiaries (≥ 65 years) with incident OA who initiated an analgesic within 30 days of diagnosis and had continuous enrollment for ≥ 365 days prior through ≥ 30 days post-index. Patients with baseline HTN were classified as OA + HTN; others as OA-only. We assessed overall analgesic trends using the Cochran-Armitage test and evaluated differences by HTN status using logistic regression with year as an interaction term. For stratified analyses by joint type, we applied weighted logistic regression. RESULTS: Among 179,033 beneficiaries (mean age 75 ± 7.3 years; 62.7% women; 80.7% White), 57.1% had baseline HTN. Overall, the most commonly initiated analgesic classes were intra-articular injections (30.3%), and oral NSAIDs only (28.2%). Notable changes from 2012 to 2022 were increase in topical NSAIDs use (3.1%-5.7%) and decrease in opioid combination use (25.4%-13.9%), with no significant trend differences by HTN status. In joint-specific analyses, OA + HTN versus OA-only showed no differences in odds of initiating oral opioids (OR: 0.97, 95% CI: 0.92-1.03), intra-articular injections (OR: 1.01, 95% CI: 0.96-1.07) or topical NSAIDs (OR: 0.88, 95% CI: 0.78-1.01) versus oral NSAIDs. CONCLUSION: Baseline HTN did not influence the choice of initial analgesic in incident OA patients. Safer, evidence-based alternatives are needed for older adults with comorbid HTN.

  PublisherDOI

• Risk of Suicidal Ideation and Behaviors, Depression, and Anxiety with GLP-1 Receptor Agonist Use in Children and Adolescents: A Target Trial Emulation Study

  medRxiv · 2025-11-13 · 1 citations

  preprintOpen access

  ABSTRACT Importance Rising rates of obesity and youth-onset type 2 diabetes (YT2D) in children and adolescents have increased GLP-1 receptor agonist (GLP-1 RA) use, raising concerns about potential effects on suicidal ideation/behaviors (SI/SB), depression, and anxiety. Objective To assess associations between GLP-1 RA use for obesity or YT2D and risk of SI/SB, depression, and anxiety in children and adolescents. Setting OneFlorida+ EHR from January 1, 2020, to January 31, 2024. Design Retrospective cohort study using prevalent-new user design, target trial emulation framework, and sIPTW for confounding control. Participants Children and adolescents with obesity or YT2D who were ≥6 and <18 years were included with no history of the respective outcomes. Exposure New GLP-1 RA users vs. Prevalent metformin users. Outcomes SI/SB, anxiety, and depression. Weighted Cox proportional hazards models were used to assess the risk of outcomes. Risk differences (RD) and hazard ratios (HR) are presented with 95% CI. RDs are per 1,000 person-years. Results The study included 2,010, 1,774, and 1,764 patients for SI/SB, depression, and anxiety, respectively. The mean age was ∼14.2 years, ∼61% were female, with up to 4 years of follow-up, across cohorts. Compared to prevalent metformin users, GLP-1 RA users had lower incidence and risk of SI/SB (RD: -10.45, -14.54 to -6.36; HR: 0.11, 0.02 to 0.86) and depression (RD: -25.64, -34.90 to -16.39; HR: 0.37, 0.17 to 0.78). There was no difference in anxiety risk between the two groups (RD: 5.95, -7.10 to 19.01; HR: 1.13, 0.69 to 1.84). Conclusions GLP-1 RA use may reduce the risks of SI/SB and depression among children and adolescents with obesity or YT2D; no association was found with anxiety. Long-term surveillance is needed. KEY POINTS Question Are GLP-1 receptor agonists (GLP-1 RAs) for the indication of obesity or youth-onset type 2 diabetes (YT2D) associated with the risk of mental health outcomes in children and adolescents? Findings In this retrospective cohort study, including 2,116 children and adolescents with obesity or T2D, GLP-1 RA use was associated with a significantly lower risk of suicidal ideation and behaviors and depression when compared to prevalent metformin users. There was no significant difference in the risk of anxiety between the two groups. Meaning The results of this study suggest that children and adolescents using GLP-1 RA for obesity or YT2D were at lower risk of suicidal ideation and behaviors, and depression compared to prevalent metformin users. The risk of anxiety remained non-significant, but the higher trend warrants future surveillance by pediatricians, psychologists, and pharmacoepidemiologists.

  PublisherOA PDFDOI

• 985-P: Continuous Glucose Monitoring and Associated Outcomes in Insulin-Using Older Adults with Diabetes and Alzheimer’s Disease and Related Dementias Using Medicare 2016–2020 Data

  Diabetes · 2025-06-13

  article

  Introduction and Objective: The co-occurrence of dementia and diabetes significantly impacts quality of life, healthcare costs, and mortality rates. Effective management of both conditions using technology like continuous glucose monitoring (CGM) could improve outcomes. Methods: This retrospective study used 2016-2020 Medicare fee-for-service claims data (15% random sample) with continuous Part A, B, and D enrollment. We included patients with diabetes and cognitive impairment/ADRD, excluding those with 2020 CGM claims, non-users without SMBG at baseline, in hospice, or with Part C enrollment. Follow-up began at the first CGM claim and ended at death, disenrollment, or Dec 31, 2020. Propensity score matching (1:1) ensured balanced cohorts (SMD <0.1). Cox proportional hazards models compared outcomes between CGM and SMBG users, with significance set at 95% CI not crossing 1. Results: In our matched cohort of 1011 CGM and 1011 SMBG users, CGM use was associated with significant reductions in all-cause hospitalizations (HR: 0.86, 95% CI: 0.76-0.96) and all-cause mortality (HR: 0.57, 95% CI: 0.48-0.67) compared to SMBG users. There were no significant differences in hypoglycemia hospitalizations, hyperglycemia, or falls. Subgroup analyses showed lower hypoglycemia risk in male CGM users (HR: 0.35, 95% CI: 0.15-0.87) and higher hyperglycemia risk in CGM users with type 1 diabetes (HR: 1.78, 95% CI: 1.15-2.75). Other subgroup findings by race/ethnicity, sex, and diabetes type aligned with overall results. Conclusion: Our findings highlight CGM's benefit in reducing all-cause mortality, hospitalizations, and hypoglycemia risk in male users among older adults with diabetes and cognitive impairment. These results support including CGM in diabetes management guidelines for this population. Disclosure P. Kotecha: Employee; Takeda Pharmaceutical Company. W.T. Donahoo: None. S.M. Smith: None. J. Bian: None. J. Guo: None.

  PublisherDOI

• Reducing hypertension with adults experiencing food insecurity in low-income communities: Identifying intervention strategies and facilitators/barriers

  Journal of Agriculture Food Systems and Community Development · 2025-01-01

  articleOpen access

  Uncontrolled blood pressure (BP) is a major risk factor of cardiovascular diseases, which is the lead­ing cause of premature deaths in the U.S. Treat­ment recommendations include increasing the con­sumption of fruits and vegetables. Individuals in impoverished areas encounter barriers to eating healthy including food insecurity, limited resources and access to fresh foods, and gaps in nutrition knowledge and skills. To improve cardiovascular health for individuals experiencing food insecurity, we sought a community’s preferences for, and per­ceived facilitators/barriers to, two categories of evidenced–based implementation strategies that increase fruit/vegetable intake and decrease BP. Participants with hypertension and food insecurity (N = 32) were recruited from Florida urban zip codes with higher rates of poverty and food insecu­rity than state and national averages. Five focus groups captured perceptions of three community health worker-led educational services (motiva­tional education session, federal food benefits, local food pantries and events) and five personal­ized services (in-store education, online recipes, online cooking videos, online cooking classes, transporta­tion). Thematic analyses captured prefer­ences and uptake facilitators/barriers. Participants supported all educational services, particularly the motiva­tional education, noting two facilitators to uptake: opportunity to learn and quality of life improve­ment. They also described access as a barrier to fed­eral food benefits indicating a need for registration assis­tance. They noted two barriers to using food pan­tries and events: lack of healthy food options and an increased feeling of vulnerability (also a barrier to using in-store education). Regarding personalized ser­vices, they preferred recipes and cooking videos (perceived as feasible opportunities to learn) and trans­portation (reduces burden). Barriers to online person­alized services included technology and inconvenience. Community input on implementation strategies among adults experiencing food insecurity demonstrated acceptability of educational and personalized services to increase fresh food access. Strategies that promote learning opportunities and feasibility, while protecting social dignity, are preferred.

  PublisherOA PDFDOI

• Abstract P2058: Hypertension in Young Adults: Social Determinants and Control Using EHR Data

  Circulation · 2025-03-11

  article

  Introduction: Young adults are at risk for long-term cardiovascular complications if hypertension (HTN) remains unmanaged. There is limited exploration of how specific social determinants of health (SDoH), particularly in young adults, influence HTN control. Methods: HTN control was assessed among young adult patients (20 to 44 years) who completed SDoH screening in the Northwestern Medicine Health System. Exposures included 6 SDoH: no usual source of care, difficulty affording medication, mental health concerns, housing instability, transportation needs, and food insecurity. Sample included participants with SDoH measures and HTN as defined per 2017 ACC/AHA guidelines or ICD-10 code between 2018 and 2024 (N=36,377). Control was defined as blood pressure (BP) <140/<90 mmHg. Multivariable regression estimated the association between specific SDoH with HTN control, adjusted for age, sex, and race/ethnicity. Results: BP control at one year was 81.7% among hypertensive young adults. Hypertensive young adults with difficulty affording medication (OR 0.74; 95% CI 0.60-0.94; P=0.011) and housing instability (OR 0.63; 95% CI 0.43-0.96; P=0.027) were less likely to be controlled compared to those without these SDoH. Non-Hispanic Black young adults with HTN were less likely to be controlled compared to Non-Hispanic White young adults (OR 0.69; 95% CI 0.56-0.86; P<0.001). Hypertensive young adults on Medicaid were less likely to be controlled than those with a commercial health plan (OR 0.79; 95% CI 0.63-1.01; P=0.053). Conclusions: Improving medication accessibility and housing stability for young adults could improve HTN control. Future research should explore strategies to integrate SDoH screening into routine hypertension care.

  PublisherDOI

• Patient Predictors of Combination Therapy as Initial Hypertension Treatment: The AOURP (All of Us Research Program) Registry

  Journal of the American Heart Association · 2025-03-26

  articleOpen access
  PublisherOA PDFDOI

• Abstract 4363507: Higher Blood Pressure Time-in-Target Range May Improve Primary Cardiovascular Outcome in Patients with Hypertension and Coronary Artery Disease

  Circulation · 2025-11-03

  articleSenior author

  Introduction: Higher blood pressure Time-in-Target Range (BP-TTR) has been associated with lower risk of cardiovascular outcomes. However, the prognostic value of BP-TTR among patients with hypertension (HTN) and coronary artery disease (CAD) remains unclear. Research Question: Is higher BP-TTR over a 6-month period associated with a reduced risk of primary cardiovascular outcome (composite all-cause mortality, nonfatal myocardial infarction, nonfatal stroke) among patients with HTN+CAD? Methods: In this post-hoc analysis of the randomized INternational VErapamil-trandolapril STudy (INVEST), we pooled patients (aged ≥50 years with HTN+CAD) randomized to a calcium antagonist or non-calcium antagonist strategy, which had equivalent outcomes in INVEST. Of 22,576 INVEST participants, we identified those with ≥4 BP readings, and without the primary outcome or loss to follow-up within the first 6 months post-randomization (including randomization date). We performed linear interpolation with constant extrapolation using eligible participants’ BP readings during this 6-month period (168 days) to estimate BP-TTR, defined as the proportion of days with BP readings below the target (140/90 mmHg) over the 168-day window. Cox proportional hazards regression was used to examine the association between BP-TTR in the first 6 months post-randomization and the primary outcome thereafter. Results: A total of 12,952 eligible participants were included (mean±SD age, 66.1±9.6 years; 48.6% men). Among four BP-TTR groups (0–25%, >25–50%, >50–75%, and >75–100%), individuals with a BP-TTR of >75–100% had the lowest incidence rate of the primary outcome (35.2 per 1,000 person-years). Compared to individuals in the lowest BP-TTR group, those in higher BP-TTR groups had a reduced risk of the primary outcome in both unadjusted and adjusted models. However, statistically significant reductions were observed only in the unadjusted model for the BP-TTR >50–75% group (hazard ratio [95% CI], 0.84 [0.71-0.99]; p=0.036), and the BP-TTR >75–100% group (0.79 [0.69-0.92]; p=0.002). Conclusions: In patients with HTN+CAD, higher BP-TTR at the target of <140/90 mmHg may be associated with a reduced risk of the composite outcome of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke, though statistical significance was not reached after adjustment. As a next step, we plan to conduct additional analyses applying alternative BP targets and assessing other outcomes in the INVEST.

  PublisherDOI

• Disparities in Initial Antihypertensive Intensity by Sex, Race and Ethnicity in Newly Treated Patients With Hypertension

  American Journal of Hypertension · 2025-04-22 · 1 citations

  articleOpen accessSenior author

  BACKGROUND: Sex, race, and ethnicity disparities in hypertension (HTN) treatment intensity have been previously described. It remains unclear if these disparities occur at treatment onset and whether they can be explained by differences in clinical factors. METHODS: We conducted a retrospective cross-sectional study of adults with newly treated HTN using linked EHR + claims data from OneFlorida + Consortium. We included Florida Medicaid & Medicare-recipients diagnosed with HTN and prescribed ≥ 1 first-line antihypertensive during 2013-2020. We used generalized linear models to estimate differences in total therapeutic intensity score (TTIS)-a patient's total daily dose (TDD) divided by recommended maximum TDD for a drug, summed across entire regimen-by sex, race, and ethnicity. We then modeled the same, controlling for demographics, blood pressure, and relevant comorbidities. RESULTS: In total 4,094 patients (mean age 58 ± 16; female 57.6%; White 56.7%) were included. We observed variations in the initiation of antihypertensive classes by sex, race and ethnicity. In univariate analyses, men averaged 7.6% (95% CI: 3.9%-11.3%) greater TTIS versus women and Black individuals averaged 10.5% (95% CI: 6.6%-14.3%) greater TTIS versus White individuals, whereas no disparities were observed by ethnicity. After adjusting for clinical factors, these disparities persisted: men had 7.6% (95% CI: 3.9%-11.4%) greater TTIS versus women, and Black individuals had 17.9% (95% CI: 13.8%-21.9%) greater TTIS versus White individuals. CONCLUSIONS: We observed disparities in treatment intensity by sex and race that were not explained by differences in clinical factors. There was sex-based variation in practice patterns, and Black individuals received more intensive initial antihypertensive therapy than White individuals.

  PublisherOA PDFDOI

• Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine

  JAMA Neurology · 2025-01-06 · 14 citations

  articleOpen access

  Importance: Monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) or its receptor (anti-CGRP mAbs) offer effective migraine-specific preventive treatment. However, concerns exist about their potential cardiovascular risks due to CGRP blockade. Objective: To compare the incidence of cardiovascular disease (CVD) between Medicare beneficiaries with migraine who initiated anti-CGRP-mAbs vs onabotulinumtoxinA in the US. Design, Setting, and Participants: This retrospective, sequential cohort study was conducted among a nationally representative population-based sample of Medicare claims from May 2018 through December 2020. Data analysis was performed from August to December 2023. This study included fee-for-service Medicare beneficiaries aged 18 years or older with migraine who initiated either anti-CGRP mAbs or onabotulinumtoxinA. Beneficiaries who had a history of myocardial infarction (MI), stroke, cluster headache, malignant cancer, or hospice service within a 1-year baseline period prior to treatment initiation were excluded. To minimize channeling bias from new drug introductions and time-related bias due to the COVID-19 pandemic, 5 cohorts were established, representing sequential 6-month calendar intervals based on the initial prescription or date of index anti-CGRP mAbs or onabotulinumtoxinA use. Exposure: Anti-CGRP mAbs vs onabotulinumtoxinA. Main Outcomes and Measures: The primary outcome was time to first MI or stroke. Secondary outcomes included hypertensive crisis, peripheral revascularization, and Raynaud phenomenon. The inverse probability of treatment-weighted Cox proportional hazards models were used to compare outcomes between the 2 treatment groups. Results: Among 266 848 eligible patients with migraine, 5153 patients initiated anti-CGRP mAbs (mean [SD] age, 57.8 [14.0] years; 4308 female patients [83.6%]) and 4000 patients initiated onabotulinumtoxinA (mean [SD] age, 61.9 [13.7] years; 3353 female patients [83.8%]). Use of anti-CGRP mAbs was not associated with an increased risk of composite CVD events (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.44-1.77), hypertensive crisis (aHR, 0.46; 95% CI, 0.14-1.55), peripheral revascularization (aHR, 1.50; 95% CI, 0.48-4.73), or Raynaud phenomenon (aHR, 0.75; 95% CI, 0.45-1.24) compared with onabotulinumtoxinA. Subgroup analyses by age group and presence of established non-MI or stroke CVD showed similar findings. Conclusions and Relevance: In this cohort study, despite initial concerns regarding the cardiovascular effects of CGRP blockade, anti-CGRP mAbs were not associated with an increased risk of CVD compared with onabotulinumtoxinA among adult Medicare beneficiaries with migraine, who were predominantly older adults or individuals with disability. Future studies with longer follow-up periods and in other populations are needed to confirm these findings.

  PublisherOA PDFDOI

Recent grants

• Antihypertensive Mechanisms of Minocycline in Resistant Hypertension: Role of the gut microbiota-brain-immune axis

  NIH · $3.9M · 2023–2029

• Advancing Personalized Hypertension Care through Big Data Science

  NIH · $726k · 2018–2023

Frequent coauthors

• Carl J. Pepine

  University of Florida

  68 shared

• Rhonda M. Cooper‐DeHoff

  University of Florida

  53 shared

• Jingchuan Guo

  Center for Drug Evaluation and Research

  45 shared

• Scott Martin Vouri

  Center for Drug Evaluation and Research

  43 shared

• Héctor Bueno

  Hospital Universitario 12 De Octubre

  36 shared

• John G. Gums

  University of Florida

  34 shared

• Haesuk Park

  University of Florida

  32 shared

• Almut G. Winterstein

  Center for Drug Evaluation and Research

  31 shared

Education

• Other

  University of Florida College of Pharmacy

• Other

  North Florida/South Georgia Veterans Health System

Awards & honors

• American Heart Association Fellow 2023
• University of Florida College of Pharmacy Excellence Award f…
• University of Florida Fellow 2018
• American College of Clinical Pharmacy Delta Omega Inductee 2…
• University of Florida College of Public Health & Health Prof…