As in the past, most Pacific Island people live today along island coasts and subsist largely on foods available both onshore and offshore. On at least two occasions in the 3500 years that Pacific Islands have been settled, sea level changes affected coastal bioproductivity to the extent that island societies were transformed in consequence. Over the past 200 years, sea level has been rising along most Pacific Island coasts causing loss of productive land through direct inundation (flooding), shoreline erosion and groundwater salinization. Responses have been largely uninformed, many unsuccessful. By the year 2100, sea level may be 1.2 m higher than today. Together with other climate-linked changes and unsustainable human pressures on coastal zones, this will pose huge challenges for livelihoods. There is an urgent need for effective and sustainable adaptation of livelihoods to prepare for future sea level rise in the Pacific Islands region. There are also lessons to be learned from past failures, including the need for adaptive solutions that are environmentally and culturally appropriate, and those which appropriate decision makers are empowered to design and implement. Around the middle of the twenty-first century, traditional coastal livelihoods are likely to be difficult to sustain, so people in the region will need alternative food production systems. Within the next 20-30 years, it is likely that many coastal settlements will need to be relocated, partly or wholly. There are advantages in anticipating these needs and planning for them sooner rather than later. In many ways, the historical and modern Pacific will end within the next few decades. There will be fundamental irreversible changes in island geography, settlement patterns, subsistence systems, societies and economic development, forced by sea level rise and other factors.