Small islands are territories that are subject to different environmental, economic and social problems and pressures. Strategic Environmental Assessment (SEA) is a systematic approach that integrates sustainability issues into policies, plans and programmes promoting the participation of different stakeholders including the communities. In this research an integrative review is performed to identify, explore and discuss the academic outlook on sustainability in small islands and SEA in their decision-making context. The study is justified by the pressing need to find suitable responses for integrating sustainability into small islands through the decision-making process. The review was conducted through academic literature that focused on sustainability and environmental assessment in islands from the last 15 years. The documents were analysed through a content analysis based approach where they were coded with pre-determined categories according with the 14 priority areas identified in the Barbados Programme of Action and the three additional priority areas from the Mauritius Strategy for addressing the special challenges faced by Small Islands Developing States. From the review it is understood that it is still not clear what sustainability is for small islands or what is the best approach to achieve it. However, three key arguments, linked with SEA, emerged from the discussion on how to enhance sustainability in these territories (i) change in decision-making paradigm, (ii) good governance and community empowerment and, (iii) resilience. SEA can help to put forward these three “sustainability enhancers” since SEA approaches addressed them, yet, it is necessary to develop or rethink a framework for SEA in these territories, promote SEA research for small islands and stimulate capacity-building.