Urbanization compound pathways of global lung cancer incidence risk under proximal and distal interactions

Lung cancer burden varies across countries undergoing different stages of urbanization, but the interacting roles of behavioral and macro-environmental factors remain difficult to quantify. Using GBD 2021 and World Bank data from 187 countries between 1991 and 2021, we combined GWRF-SHAP to examine nonlinear and spatially heterogeneous interactions between urbanization, proximal behavioral factors, and distal socio-environmental contexts. Lung cancer incidence shifted from traditionally developed regions toward rapidly urbanizing areas. Urbanization-occupational exposure and urbanization-forest cover emerged as the dominant interaction pathways, ranking first in 103 and 33 countries, respectively. Air pollution tended to amplify risk in rapidly urbanizing countries, whereas forest-related interactions generally showed buffering patterns with regional exceptions. Consequently, when formulating geographically differentiated lung cancer prevention strategies, it is essential to consider the combined impact of occupational health management, pollution control, the transition to clean energy, and environmental planning.