Background: The aim of the SMOOTH(San Marino Observational Outlooking Trial on Hypertension) study was to explore hypertension awareness, treatment and control and the associated metabolic abnormalities and risk factors in the population of San Marino, a small state in the Mediterranean area, for which limited evidence is available. Methods: Nine general practitioners enrolled 4590 consecutive subjects(44%of the SanMarino population age 40-75 years), seen in their office by collecting history, physical and laboratory data and office blood pressure(BP) measurements. Results: Of these subjects, 2446 were normotensive and 2144 hypertensive; 62.3%of hypertensive patients were aware of their condition, 58.6%were treated(monotherapy 31.5%, combination therapy 27.1%), and 21.7%were controlled. Hypertension awareness and treatment were more frequent above age 50 and in females; BP control was similarly low in both genders. As compared to normotensives, hypertensive subjects were less frequently smokers(20.1 versus 27.8%), had greater body mass index(28.1±4.5 versus 25.8±3.7 g/m2), and a higher prevalence of diabetes mellitus(15.8 versus 6.3%), lower high-density lipoprotein(HDL) cholesterol and higher prevalence of increased blood total cholesterol(66.1 versus 51.3%), triglycerides and serum uric acid. Values of subjects with ’high-normal’blood pressure were closer to those of hypertensive subjects. The prevalence of metabolic syndrome was higher in hypertensive than in normotensive subjects,and in treated than in untreated hypertensives. Conclusions: Even in a small Mediterranean country with high health-care standards, hypertension awareness, treatment and control are inadequate and hypertension clusters with metabolic abnormalities and risk factors as in non-Mediterranean areas. Background: The aim of the SMOOTH (San Marino Observational Outlooking Trial on Hypertension) study was to explore hypertension awareness, treatment and control and the associated metabolic abnormalities and risk factors in the population of San Marino, a small state in the Mediterranean area, for Methods: Nine general practitioners enrolled 4590 consecutive subjects (44% of the SanMarino population age 40-75 years), seen in their office by collecting history, physical and laboratory data and office blood pressure (BP) measurements. Results: Of these subjects, 2446 were normotensive and 2144 hypertensive; 62.3% of hypertensive patients were aware of their condition, 58.6% were treated (monotherapy 31.5%, combination therapy 27.1%), and 21.7% were controlled. Hypertension awareness and treatment were more frequent above age 50 and in females; BP control was similarly low in both genders. As compared to normotensives, hypertensive subjects were less frequentl (20.1 versus 27.8%), had greater body mass index (28.1 ± 4.5 versus 25.8 ± 3.7 g / m2), and a higher prevalence of diabetes mellitus (15.8 versus 6.3%), lower high-density lipoprotein and higher prevalence of increased blood total cholesterol (66.1 versus 51.3%), triglycerides and serum uric acid. Values ​​of subjects with ’high-normal’blood pressure were closer to those of hypertensive subjects. The prevalence of metabolic syndrome was higher in hypertensive than in normotensive subjects, and in treated smaller than with untreated hypertensives. Conclusions: Even in a small Mediterranean country with high health-care standards, hypertension awareness, treatment and control are inadequate and hypertension clusters with metabolic abnormalities and risk factors as in non-Mediterranean areas .