ObjectiveTo examine the efficacy of school-based e-cigarette preventive interventions via a systematic review and meta-analysis.Data sourcesWe searched MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane and clinical trials registries for studies published between January 2000-June 2023 using keywords for e-cigarettes, adolescents, and school.Study selectionOf 1566 double-screened records, 11 met criteria of targeting adolescents, evaluating an e-cigarette preventive intervention, being conducted in a secondary school, using a randomised controlled trial (RCT), cluster RCT or quasi-experimental design, and comparing an intervention to a control.Data extractionPre-specified data pertaining to the study design, outcomes, and quality were extracted by one reviewer and confirmed by a second, and where necessary, third reviewer.Data synthesisOur narrative synthesis showed some school-based interventions prevented or reduced e-cigarette and/or tobacco use, however some increased use. Meta-analyses on a subsample of studies found that, overall, school-based interventions were not associated with the prevention of e-cigarette (OR=0.43, 95%CI=0.16, 1.12; p=0.09) or tobacco (OR=1.01, 95%CI=0.65, 1.59, p=0.95) use, however were associated with reductions in past 30-day tobacco use (OR=0.59, 95%CI=0.39, 0.89, p=0.01) which encompassed e-cigarettes in some studies. School-based interventions were also associated with improved knowledge (SMD=-0.38, 95%CI=-0.68, -0.08, p=0.01), intentions (SMD=-0.15, 95%CI=-0.22, -0.07, p=0.0001), and attitudes (SMD=-0.14, 95%CI=-0.22, -0.06; p=0.0007) in the short-term. Overall, the quality of evidence was low-to-moderate.ConclusionsSchool-based interventions hold potential for addressing e-cigarette use, however, can have null or iatrogenic effects. More high-quality research is needed to develop efficacious interventions, and schools must be supported to adopt evidence-based programs.