The United States banned the manufacture and consumer use of lead-based paint in 1978. However, numerous homes were finished with paints containing lead pigments before enactment of that legislation. More than half of owner-occupied homes were built before 1980, and approximately 38% were built before 1970.¹ The most common sources of lead exposure are lead paint; lead-contaminated dust, soil, and water; and lead containing products.² However, deteriorating lead-based paint and lead dust is found in poorly maintained older housing, housing undergoing renovation or repainting without the use of lead safe work practices, and is the primary source of lead exposure among US children.^3,4 No safe blood lead level has been identified.⁵ Potential lead exposures in older homes are exacerbated through construction, remodeling, and other procedures that circulate lead dust and expose old paint layers that might contain lead.⁶

In 1992, the US Congress passed the Residential Lead-Based Paint Hazard Reduction Act (known as Title X). Section 1018 of Title X requires the US Department of Housing and Urban Development (HUD) and the US Environmental Protection Agency (EPA) to promulgate a lead paint disclosure rule. The rule (adopted in 1996) requires that buyers and renters of residential dwellings built before 1978 be notified by the seller or landlord that exposure to lead could result from past use of lead-based paint at the property.^7,8 Federal law requires home sales to include (1) an EPA, HUD, and Consumer Product Safety Commission-approved information brochure on identifying and controlling lead-based paint hazards (“Protect Your Family From Lead In Your Home”); (2) disclosure of any known information concerning the presence of lead-based paint and/or lead-based paint hazards in the home; (3) an attachment to the contract, or language inserted in the contract, that includes a lead warning statement and confirms that the seller has complied with all notification requirements; and (4) a 10-day period to conduct a paint inspection or risk assessment for lead-based paint hazards if so desired by the buyer or seller.⁸

Radon, another potential hazard in the home, is an odorless and colorless radioactive gas. Radon is the leading cause of lung cancer among nonsmokers and is responsible for approximately 21 000 lung cancer deaths annually.⁹ Lead and radon in homes can be mitigated and treated, but part of their danger is that they can go unnoticed by the residents. Home buyers who are more knowledgeable about potential risks from lead and radon in their homes might be more likely to test their homes for both.^10,11

To understand residential home buyers’ lead and radon knowledge, attitudes, and protection behaviors, we built upon the findings of Neri and colleagues.¹² Those researchers assessed radon-related knowledge, attitudes, and behaviors among recent home buyers in 4 states: Illinois, Minnesota, North Carolina, and Ohio. The present study focused on survey questions about lead Title X requirements. These states have enacted policies that offer awareness and protection from lead and radon during the home-buying process. Illinois and Ohio have enacted laws to support Title X lead disclosure during the home buying process.^13,14 Minnesota and North Carolina have worked to increase awareness and compliance of Title X through their lead poisoning prevention programs.^15,16 For radon exposure prevention, all 4 states require that previously identified levels of radon be disclosed at the time of purchase. Illinois and Minnesota also mandate disclosures and education regarding radon.^17,18 Ohio’s residential property disclosure form lists lead-based paint and radon.¹⁹

The Flint, Michigan, water crisis was during the home buyer survey period, which occurred during July 2015 through January 2016.²⁰ We hypothesized that the lead contamination of drinking water in Flint and subsequent intense media coverage raised national awareness about the harmful effects of lead exposure. We investigated if this increased awareness of lead exposure might differ among home buyers before and after the dates of the Flint water crisis. To assess the potential effect of the Flint water crisis media coverage on participant’s lead knowledge, attitudes, and behaviors, we compared data for pre- and post-Flint water crisis periods (before September 24, 2015, and on or after that date).

This study explores the associations between knowledge, attitudes, and behaviors specifically related to lead (and the relationship to radon); influence on home-buying decisions; sources of home buyer knowledge; and whether the purchased homes abided by the federal lead disclosure rule (as reported by home buyers).

The overall survey (N = 995) response rate was 33%. Response rates varied significantly (P < .001) by state, with North Carolina and Minnesota having the highest response rates. Most responses (48%) resulted from the first mailing. Compared with 2015 census data, this respondent group had a higher proportion of non-Hispanic/Latino, White and younger persons with college degrees.

This is the first study we are aware of that examines lead exposure home buyer knowledge, attitudes, and behaviors associated with the purchase of pre-1978 homes. Our multistate study of recent pre-1978 home buyers shows that virtually all were aware of health issues associated with lead exposure. One explanation may be that virtually all respondents were not buying their first home and had more opportunity to learn about household lead exposure health issues. This knowledge is higher than reported in a previous study. In that report, among 282 homeowners in 3 greater Omaha, Nebraska, neighborhoods, 50% to 71% reported seeing or receiving information about lead poisoning.²³ We hypothesized that home buyer’s knowledge of health issues caused by lead would be higher among home buyers purchasing after the Flint water crisis. However, in multivariable analysis, we did not observe any differences among home buyers based on awareness created by the media coverage.

More than half of our sample of recent pre-1978 home buyers reported not signing or being unsure of signing (or seller not signing) lead disclosure paperwork during closing. This identifies possible collaboration for agencies like EPA, HUD, and health departments to increase Title X compliance. A national survey of 1035 US residents conducted during 2020-2021 found that lead exposure risk was not an issue of high concern among the general US population.²⁴ This finding contextualizes the opportunity that exists to make home buyers aware of potential lead exposure risks. In our study, home buyers not signing lead disclosure paperwork was consistent across all respondent demographic and survey questions, except for one. Home buyers with five or more previous home purchases were more likely to report that documentation of the lead disclosure process occurred. We did not find any studies indicating that persons with previous home buyer experience are more aware of the lead disclosure rule.

For dwellings built before 1978, HUD makes available to real estate agents a seller’s information disclosure attachment to the closing contract, or language inserted in the contract, that includes a lead warning statement and confirms that the seller has complied with all notification requirements.²⁵ This lead-based paint and/or lead-based paint hazards disclosure contains signature lines for the seller, buyer, and real estate agent. However, in our sample, more than half of recent home buyers did not sign or did not recall signing such a document. Timing of signing might be a potential reason some home buyers are not sure they signed lead disclosure paperwork. Weissman (2006) reports that a common way real estate agents avoid complying with Title X is by attaching the seller’s property disclosure statement (containing the lead-based paint disclosures) to the contract after the contract is signed by all parties.²⁶ In this situation, the buyer is presented with the decision to buy the home before receiving the lead-based paint disclosures. Real estate agents perform the perfunctory requirements of ensuring lead disclosure paperwork is filled out and providing lead and radon educational material (often grouped in with other materials).

Our analysis focused on predictors of the home buyer decision to buy the home based on their understanding of health issues related to lead-based paint exposure. Only 22% said this knowledge affected their home buying decision, which was the outcome variable. We identified two predictors affecting the home buyer decision to purchase the home: (1) a real estate agent who discussed lead-based paint during the home buying experience and (2) home buyer awareness of contractors in the area who work on lead-based paint.

Real estate agents are important partner in the home buying experience. They were the second most frequent source of home buyer information about health information related to lead exposure (and the most common for radon health information). During the time of this study, home buyers utilized real estate agents 88% of the time and they were considered a “very useful” source of information 79% of the time.²⁷ A 2013 study of homeowners noted from focus groups that real estate agents are trustworthy sources for carbon monoxide education.²⁸ A study by Phoenix and colleagues looked at the effects of educating licensed real estate agents about lead hazards.²⁹ The researchers found that after training, real estate agents were more likely to act with greater concern for the home buyer’s welfare regarding reduction of lead hazards. Real estate agents have an opportunity to encourage lead testing and potential remediation during the time of home sales. The Ohio Lead Advisory Council includes an appointed member from the Ohio Real Estate Trade Organization.³⁰ This provides opportunity for discussion related to transparency about lead information during real estate transactions (personal communication with John Belt, Ohio Bureau of Environmental Health and Radiation Protection, February 5, 2024).

We did not identify previous studies describing home buyer awareness of contractors influencing the decision to buy an older home. However, home buyers receiving Title X lead disclosure information have increased probability to perform lead testing.¹⁰

Respondents who bought homes built before 1978 consistently reported more awareness, knowledge, and practice of radon exposure prevention than of lead exposure prevention. These areas concerned 5 questions about (1) the home buying process, (2) real estate agent discussion about lead and radon, (3) signing disclosure paperwork at closing, (4) receipt of lead and radon brochures, and (5) knowledge of contractors who test and repair for lead and radon. The reason for increased radon knowledge, awareness, and practice compared with that for lead is unclear. At the time of the survey, Illinois and Minnesota had state radon notification policies and Illinois and Ohio had state-managed radon professional licensure requirements.²¹ Those policies and requirements might have contributed to increased radon awareness, knowledge, and practice in the study sample. Radon policies require buyers, sellers, and real estate agents involved in the purchase of single-family homes to receive radon informational brochures and sign an acknowledgement that the property had or had not been tested for radon. Radon professional certification policies require radon mitigation professionals to be licensed by a state agency. Another possible reason for increased home buyer attention to radon compared to lead is the fact that all 4 survey states are mostly located in EPA radon zones 1 and 2. Zone 1 has the highest potential for indoor radon exposure and zone 2 has moderate exposure potential.³¹ This fact might have the effect of increased awareness among real estate agents and home buyers. Cost may be another factor contributing to the difference. Residential lead testing and abatement cost is generally higher compared to residential radon testing and mitigation. Depending on the location and size of home, certified residential lead inspection can cost $500 to $2500.^32,33 Home buyers can also expect to pay an additional $20 to $100 if they want their drinking water tested for presence of lead by a certified laboratory.³⁴ The average cost for certified residential lead paint abatement work in Baltimore averages $7,600.³⁵ Professional residential radon testing costs range from $50 to $150.³⁶ Licensed professional radon mitigation can cost between $800 and $2500.^17,37 To assist home buyers with lead testing and abatement costs by licenses professionals, Ohio enacted a lead abatement tax credit program capped at $10,000 per taxpayer and per eligible pre-1978 dwelling.³⁸ This program began in 2020.

We found one state-to-state difference among home buyers. In North Carolina, respondents who understood the health issues related to lead-based paint had their home buyer decision affected more than were respondents from the other 3 states. Analyzing, interpreting, and understanding the effects of differences in state policies and attributing them to home buyer responses is complex. Future studies can analyze differences by state to determine if state policies influence home buyer behavior and knowledge. Regardless of current state lead disclosure policies, real estate agents are valuable partners for communication of home-related health issues to home buyers and sellers. Their interaction with buyers and sellers can help to bring about outcomes to decrease lead exposure and be a resource for lead-abatement contractors. Ohio has developed and is using its own residential property disclosure form, which includes checklists for lead-based paint and radon.¹⁹ The North Carolina Lead-Based Paint Hazard Management Program, which is funded and authorized by EPA, provides education related to disclosure, which might have an even broader reach.³⁹

As expected, compared with persons who bought homes built post-1977, persons who bought homes built pre-1978 were more likely to have discussed lead issues with their real estate agent, signed lead disclosure paperwork, and received educational brochures during inspection or closing. Regardless of when the house being purchased was built, we did not find differences in whether the home buyer’s decision to purchase the home was affected by health issues caused by lead exposure or knowledge of contractors in the area who test for and fix lead-based paint issues.

This study is subject to several limitations. The response rate of 33% is lower than reported for other mail survey response rates (50%).⁴⁰ Respondents might not be representative of the 4 states surveyed, and generalizability of these results should be interpreted with caution. Home buyers were not asked if they had children. We speculate that respondents with children might be more likely to be concerned about lead-based paint disclosure and remember signing lead disclosure paperwork; however, we were not able to analyze this information. We were not able to obtain the purchase price of the home. We would have liked to assess the relationship between purchase price and whether real estate agents discussed lead-based paint with the home buyer. The survey did not ascertain the home buyer’s intended use of the property. While it is possible that a small proportion of homes may have been for investment, it is likely that a large majority of these would have been excluded from the sample. All purchased properties excluded names where the buyer was listed as something other than a person (e.g., corporation or Limited Liability Company). Lastly, as with most surveys, self-reported data might be subject to social desirability in responses or recall bias.

With lead still present in tens of millions of homes and lead dust the main source of lead exposure among children, increasing the number of home buyers who acknowledge, and sign lead disclosure paperwork is important to potentially prevent lead exposure. During the home buying experience, the role that real estate agents play and home buyer awareness of local contractors who work on lead-based paint are important influences in the decision to buy the home. Further study is needed to understand why home buyers in our sample did not sign lead disclosure paperwork as required by state and federal guidelines. Home buyers had greater knowledge, awareness, and practice of radon prevention than of lead prevention, suggesting the need to further study the discrepancy and to strategize about ways to increase knowledge, awareness, and practice of lead exposure prevention. Future studies may focus on homeowners with young children in more racially diverse locations. A cohort study is an appropriate study design to assess if homeowners improved their home environment (eg, employed lead safe repairs).