The potential legalisation of liquid nicotine in Australia has posed a conundrum for a Victorian coroner investigating the death of a toddler.
The 18-month-old boy, who cannot be named for legal reasons, died in June 2018 after consuming the potent liquid his mother had poured into bottles of vape juice as she tried to quit smoking.
The sale, possession and use of liquid nicotine - a tobacco extract used in e-cigarettes - is illegal in Australia, but can be ordered from overseas and used for medicinal purposes including giving up smoking.
Coroner Phillip Byrne on Wednesday noted that while legalising liquid nicotine could help reduce its risks, he wasn't prepared to recommend law changes.
"I see a conundrum; if the product is banned in Australia, how can we in this country enforce safeguards like tamper-proof packaging of a product manufactured overseas and accessed online illegally," he wrote in his findings.
"At first blush, the legalisation in Australia of liquid nicotine for use in vaping liquid has a logical attraction if it enables regulation of content and safeguard packaging.
"However ... the issues are far more complex, indeed controversial than I initially thought."
Mr Byrne also said buying into the debate "would be akin to sailing into a maelstrom".
"I am not prepared to make any recommendation that would alter the status quo. Ultimately, legislative change is a matter for government," he added.
In the case of the toddler, the boy's mother had turned away for just a short time at their northwestern suburban home before finding a bottle of liquid nicotine open and in her child's mouth.
The coroner found the boy's death in hospital 11 days later was not the result of neglect but a momentary lapse of vigilance.
The child was much-loved and well-cared for and everything possible was done to save his life.
Mr Byrne called on Victoria's Department of Health and Human Services to conduct an awareness campaign about liquid nicotine.
It's classified as a dangerous poison in Australia but importation of up to three months' worth for therapeutic use is permitted with a prescription.
Before reaching his findings, the coroner received submissions from agencies including Quit Victoria and the Australian Tobacco Harm Reduction Association, the latter of which wants the ban on vaping nicotine overturned.